Provider Demographics
NPI:1609158369
Name:PETERSEN, TIMOTHY DANIEL (RPH)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DANIEL
Last Name:PETERSEN
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 1:2045 S I 75 BUSINESS LOOP
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-2039
Mailing Address - Country:US
Mailing Address - Phone:989-344-0374
Mailing Address - Fax:989-344-0968
Practice Address - Street 1:2045 S I 75 BUSINESS LOOP
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-2039
Practice Address - Country:US
Practice Address - Phone:989-344-0374
Practice Address - Fax:989-344-0968
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist