Provider Demographics
NPI:1619296894
Name:PETERSON, PAUL DENNIS
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DENNIS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MACINNES DR
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1144
Mailing Address - Country:US
Mailing Address - Phone:906-483-1818
Mailing Address - Fax:906-483-1811
Practice Address - Street 1:600 MACINNES DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1144
Practice Address - Country:US
Practice Address - Phone:906-483-1818
Practice Address - Fax:906-483-1811
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist