Provider Demographics
NPI:1710102561
Name:PETERSEN, TRACY C (RPH)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:C
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E KIRKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-1719
Mailing Address - Country:US
Mailing Address - Phone:515-280-3781
Mailing Address - Fax:
Practice Address - Street 1:8601 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2201
Practice Address - Country:US
Practice Address - Phone:515-270-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist