Provider Demographics
NPI:1851677843
Name:MAGNUSON, PETER (PHARMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MAGNUSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 E CLOVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:802 E CLOVERLAND DR
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1502
Practice Address - Country:US
Practice Address - Phone:906-932-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-23
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist