Provider Demographics
NPI:1801976493
Name:PETERSON, MARIAN K
Entity type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARIAN
Other - Middle Name:K
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPHTECH
Mailing Address - Street 1:210 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:DILWORTH
Mailing Address - State:MN
Mailing Address - Zip Code:56529-1225
Mailing Address - Country:US
Mailing Address - Phone:218-233-8944
Mailing Address - Fax:
Practice Address - Street 1:306 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4820
Practice Address - Country:US
Practice Address - Phone:701-271-6391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND194183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician