MEDICARE: DR. NICOLE MARIE PETERSEN PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2003023575	MO
2	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1144227448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE MARIE PETERSEN PHARM.D.

Provider Business Mailing Address
First Line	:	6625 ALAMO AVE
Second Line	:	APT 1E
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-3129
Country	:	US
Telephone Number	:	314-446-8555
Fax Number	:	314-446-8500

Provider Business Practice Location Address
First Line	:	8200 N LINDBERGH BLVD
Second Line	:	SCHNUCKS PHARMACY
City	:	FLORISSANT
State	:	MO
Zip	:	63031-7107
Country	:	US
Telephone Number	:	314-921-7345
Fax Number	:	314-921-7346

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/09/2007

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