Provider Demographics
NPI:1548608649
Name:PETERSEN, MARK EUGENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:PETERSEN
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 1:140 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1040
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-331-1612
Practice Address - Street 1:140 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1040
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-331-1612
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60341057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist