Provider Demographics
NPI:1437735776
Name:PETERSON, SHAWN KEITH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:KEITH
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9317 CERULEAN DR APT 305
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4764
Mailing Address - Country:US
Mailing Address - Phone:860-608-2200
Mailing Address - Fax:
Practice Address - Street 1:4525 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-6311
Practice Address - Country:US
Practice Address - Phone:813-261-6086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist