Provider Demographics
NPI:1417106568
Name:PETERSON, JENNIFER L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CHURCH ST SE
Mailing Address - Street 2:BOYNTON PHARMACY
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0222
Mailing Address - Country:US
Mailing Address - Phone:612-624-7655
Mailing Address - Fax:
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:BOYNTON PHARMACY
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:612-624-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-13
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist