Provider Demographics
NPI:1740502061
Name:PETERSON, BROOKE A
Entity type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MONTERREY TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:MI
Mailing Address - Zip Code:48893-8204
Mailing Address - Country:US
Mailing Address - Phone:989-644-8088
Mailing Address - Fax:
Practice Address - Street 1:2125 S MISSION ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4426
Practice Address - Country:US
Practice Address - Phone:989-773-6991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist