Provider Demographics
NPI:1407239338
Name:PETERSEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:DE SMET
Mailing Address - State:SD
Mailing Address - Zip Code:57231-2230
Mailing Address - Country:US
Mailing Address - Phone:605-854-9033
Mailing Address - Fax:605-854-9114
Practice Address - Street 1:213 CALUMET AVE SW
Practice Address - Street 2:
Practice Address - City:DE SMET
Practice Address - State:SD
Practice Address - Zip Code:57231-2161
Practice Address - Country:US
Practice Address - Phone:605-854-9033
Practice Address - Fax:605-854-9114
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist