Provider Demographics
NPI:1831190131
Name:PETERSON, CONNIE MARIE (RPH)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
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 1:2310 COULEE CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:WOODWORTH
Mailing Address - State:LA
Mailing Address - Zip Code:71485-9732
Mailing Address - Country:US
Mailing Address - Phone:318-442-0229
Mailing Address - Fax:
Practice Address - Street 1:2351 VANDENBURG DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-5609
Practice Address - Country:US
Practice Address - Phone:318-483-7336
Practice Address - Fax:318-483-7088
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13816OtherBOARD OF PHARMACY