Provider Demographics
NPI:1932493988
Name:PETERSON, MIKAEL BRIAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MIKAEL
Middle Name:BRIAN
Last Name:PETERSON
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 1:1225 W IRVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85714-1167
Mailing Address - Country:US
Mailing Address - Phone:520-295-3608
Mailing Address - Fax:
Practice Address - Street 1:1225 W IRVINGTON RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1167
Practice Address - Country:US
Practice Address - Phone:520-295-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist