Provider Demographics
NPI:1245658095
Name:PETERSON, KAMERON (PHARMD)
Entity type:Individual
Prefix:
First Name:KAMERON
Middle Name:
Last Name:PETERSON
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 1:2538 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-8820
Mailing Address - Country:US
Mailing Address - Phone:608-837-2867
Mailing Address - Fax:855-773-9176
Practice Address - Street 1:2538 IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-8820
Practice Address - Country:US
Practice Address - Phone:608-837-2867
Practice Address - Fax:855-773-9176
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-30
Last Update Date:2014-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15903-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist