Provider Demographics
NPI:1972372381
Name:PETES, ELLEN (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:PETES
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 1:1760 BERNARDY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-8840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 WATERFRONT DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4458
Practice Address - Country:US
Practice Address - Phone:319-354-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist