Provider Demographics
NPI:1598038317
Name:PETERSON, ROYCE G (PHARMD)
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:G
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 1:700 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-2212
Mailing Address - Country:US
Mailing Address - Phone:541-523-0607
Mailing Address - Fax:541-523-0589
Practice Address - Street 1:700 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-2212
Practice Address - Country:US
Practice Address - Phone:541-523-0607
Practice Address - Fax:541-523-0589
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0012258183500000X
IDP6405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0012258OtherSTATE PHARMACIST LICENSE
IDP6405OtherSTATE PHARMACY LICENSE