Provider Demographics
NPI:1386008639
Name:PETERSON, TERITA (RPH)
Entity Type:Individual
Prefix:
First Name:TERITA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99794
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60696-7594
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7930 WOODLAND CENTER BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2436
Practice Address - Country:US
Practice Address - Phone:813-881-0949
Practice Address - Fax:813-884-8782
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist