Provider Demographics
NPI:1922729441
Name:PETERSON, QUENDALL (RPH)
Entity Type:Individual
Prefix:
First Name:QUENDALL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7418 HARBOR COVE LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6199
Mailing Address - Country:US
Mailing Address - Phone:678-689-3831
Mailing Address - Fax:
Practice Address - Street 1:4550 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2050
Practice Address - Country:US
Practice Address - Phone:770-969-0267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist