Provider Demographics
NPI:1578614897
Name:PETERSON, ANDREW NUZUM (RPH)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:NUZUM
Last Name:PETERSON
Suffix:
Gender:M
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54634-0037
Mailing Address - Country:US
Mailing Address - Phone:608-489-2373
Mailing Address - Fax:608-489-2821
Practice Address - Street 1:727 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634-6229
Practice Address - Country:US
Practice Address - Phone:608-489-3141
Practice Address - Fax:608-489-2821
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI9302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist