Provider Demographics
NPI:1437289824
Name:PETERSON, ELLEN (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
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 1:1609 W PRAIRIE WOOD CT
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226-1164
Mailing Address - Country:US
Mailing Address - Phone:515-984-9267
Mailing Address - Fax:
Practice Address - Street 1:2809 100TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-3860
Practice Address - Country:US
Practice Address - Phone:515-252-7688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist