Provider Demographics
NPI:1497125835
Name:PETERSON, SAMANTHA LEA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:LEA
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 1:401 2ND ST
Mailing Address - Street 2:
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1302
Mailing Address - Country:US
Mailing Address - Phone:712-364-2120
Mailing Address - Fax:
Practice Address - Street 1:401 2ND ST
Practice Address - Street 2:
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1302
Practice Address - Country:US
Practice Address - Phone:712-364-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist