Provider Demographics
NPI:1780838680
Name:PETERSON, JOHN J (DPH)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 MINT MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-2542
Mailing Address - Country:US
Mailing Address - Phone:865-982-5378
Mailing Address - Fax:
Practice Address - Street 1:131 MONTGOMERY LN
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-5649
Practice Address - Country:US
Practice Address - Phone:865-681-0520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist