Provider Demographics
NPI:1134401847
Name:PETERSON, AUDRA (PHARMD)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:
Other - Last Name:WITHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-1242
Mailing Address - Country:US
Mailing Address - Phone:317-858-7834
Mailing Address - Fax:
Practice Address - Street 1:20 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1242
Practice Address - Country:US
Practice Address - Phone:317-858-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021129A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist