Provider Demographics
NPI:1972833002
Name:HENDRICKSON, PETER JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:HENDRICKSON
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 1:21274 N JOHN WAYNE PKWY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-8952
Mailing Address - Country:US
Mailing Address - Phone:520-568-0672
Mailing Address - Fax:
Practice Address - Street 1:21274 N JOHN WAYNE PKWY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-8952
Practice Address - Country:US
Practice Address - Phone:520-568-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS014671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist