Provider Demographics
NPI:1851687073
Name:PETERSON, JAMIE (RPH)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W IL ROUTE 60
Mailing Address - Street 2:T-1912
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4267
Mailing Address - Country:US
Mailing Address - Phone:847-367-2660
Mailing Address - Fax:847-367-2660
Practice Address - Street 1:3100 W IL ROUTE 60
Practice Address - Street 2:T-1912
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-4267
Practice Address - Country:US
Practice Address - Phone:847-367-2660
Practice Address - Fax:847-367-2660
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist