Provider Demographics
NPI:1720374903
Name:PETERSON, JAN MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 W BROADWAY AVE
Mailing Address - Street 2:T-0003
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3507
Mailing Address - Country:US
Mailing Address - Phone:763-533-1651
Mailing Address - Fax:763-252-2005
Practice Address - Street 1:5537 W BROADWAY AVE
Practice Address - Street 2:T-0003
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3507
Practice Address - Country:US
Practice Address - Phone:763-533-1651
Practice Address - Fax:763-252-2005
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-25
Last Update Date:2011-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist