Provider Demographics
NPI:1205136157
Name:PETERSEN, JAMES (PHARMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:PETERSEN
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 1:9101 E BASELINE RD.
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-6752
Mailing Address - Country:US
Mailing Address - Phone:480-281-0180
Mailing Address - Fax:480-281-0165
Practice Address - Street 1:9101 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-7758
Practice Address - Country:US
Practice Address - Phone:480-281-0180
Practice Address - Fax:480-281-0165
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist