Provider Demographics
NPI:1407272065
Name:PETERSON, CHAX BRANDON (PHARM D)
Entity Type:Individual
Prefix:
First Name:CHAX
Middle Name:BRANDON
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16654 N MORGAN LN
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5015
Mailing Address - Country:US
Mailing Address - Phone:208-651-6195
Mailing Address - Fax:
Practice Address - Street 1:8093 N CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8753
Practice Address - Country:US
Practice Address - Phone:208-762-9355
Practice Address - Fax:208-762-9198
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist