Provider Demographics
NPI:1639646557
Name:ECONOMEN, PETER JAMES (PHARMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:ECONOMEN
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 1:150 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-4205
Mailing Address - Country:US
Mailing Address - Phone:707-961-0464
Mailing Address - Fax:
Practice Address - Street 1:150 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-4205
Practice Address - Country:US
Practice Address - Phone:707-961-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist