Provider Demographics
NPI:1457564916
Name:PETERSON, MARY BETH (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 QUINN AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IA
Mailing Address - Zip Code:50607-9708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HY-VEE DRUGSTORE #7026
Practice Address - Street 2:2001 BLAIRS FERRY RD NE
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-393-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist