Provider Demographics
NPI:1730294430
Name:PETERSEN, JOHN G (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2510
Mailing Address - Country:US
Mailing Address - Phone:856-232-0230
Mailing Address - Fax:
Practice Address - Street 1:193 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1417
Practice Address - Country:US
Practice Address - Phone:856-678-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01431300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI01431300OtherPHARMACIST LICENSE