Provider Demographics
NPI:1821547621
Name:PETERSON, NICOLE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
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 1:2635 BRET AVE
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-7700
Mailing Address - Country:US
Mailing Address - Phone:785-410-5374
Mailing Address - Fax:
Practice Address - Street 1:1201 W CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4657
Practice Address - Country:US
Practice Address - Phone:785-827-0417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist