Provider Demographics
NPI:1821709460
Name:PETERSEN, STEVEN JR
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:PETERSEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6313 E ROCHELLE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-0709
Mailing Address - Country:US
Mailing Address - Phone:602-690-8294
Mailing Address - Fax:
Practice Address - Street 1:150 E OLD WEST HWY
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-0002
Practice Address - Country:US
Practice Address - Phone:480-288-2143
Practice Address - Fax:480-982-6245
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS026171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist