Provider Demographics
NPI:1972643237
Name:PETERSON, PATRICIA (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICIA
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 1:22500 ANGEL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:ID
Mailing Address - Zip Code:83545-8059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-2625
Practice Address - Country:US
Practice Address - Phone:208-476-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP5043OtherSTATE PHARMACIST LICENSE