Provider Demographics
NPI:1619375052
Name:PETERSON, ALYCE ESTELLE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:ALYCE
Middle Name:ESTELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MISS
Other - First Name:ALYCE
Other - Middle Name:ESTELLE
Other - Last Name:RENEBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:300 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:67661-1930
Mailing Address - Country:US
Mailing Address - Phone:785-543-5131
Mailing Address - Fax:785-543-5844
Practice Address - Street 1:300 STATE ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:KS
Practice Address - Zip Code:67661-1930
Practice Address - Country:US
Practice Address - Phone:785-543-5131
Practice Address - Fax:785-543-5844
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-16021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist