Provider Demographics
NPI:1356911937
Name:PETERSON, FREDERICK N
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:N
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47463-0221
Mailing Address - Country:US
Mailing Address - Phone:765-729-5479
Mailing Address - Fax:
Practice Address - Street 1:9048 W STATE ROAD 45 # 221
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:IN
Practice Address - Zip Code:47463-9000
Practice Address - Country:US
Practice Address - Phone:765-729-5479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018068A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist