Provider Demographics
NPI:1578837365
Name:PETERSON, JOHN CLAYTON (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLAYTON
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17719 LANDMARK CT
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5229
Mailing Address - Country:US
Mailing Address - Phone:952-898-0637
Mailing Address - Fax:952-898-0637
Practice Address - Street 1:700 DIVISION ST S
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2427
Practice Address - Country:US
Practice Address - Phone:507-645-4455
Practice Address - Fax:507-645-6912
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist