Provider Demographics
NPI:1841627601
Name:PETERDY, NOLAND (PHARMD, JD, MBA)
Entity type:Individual
Prefix:
First Name:NOLAND
Middle Name:
Last Name:PETERDY
Suffix:
Gender:M
Credentials:PHARMD, JD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 727
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1423 N MOLTER 727
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:509-220-7512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA39210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist