Provider Demographics
NPI:1609176163
Name:PETERSEN, MARY JANEEN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANEEN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4495 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-4915
Mailing Address - Country:US
Mailing Address - Phone:925-455-2522
Mailing Address - Fax:925-455-2525
Practice Address - Street 1:4495 FIRST ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-4915
Practice Address - Country:US
Practice Address - Phone:925-455-2522
Practice Address - Fax:925-455-2525
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist