Healthcare Provider Details

I. General information

NPI: 1821709460
Provider Name (Legal Business Name): STEVEN PETERSEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E OLD WEST HWY
APACHE JUNCTION AZ
85119-0002
US

IV. Provider business mailing address

6313 E ROCHELLE ST
MESA AZ
85215-0709
US

V. Phone/Fax

Practice location:
  • Phone: 480-288-2143
  • Fax: 480-982-6245
Mailing address:
  • Phone: 602-690-8294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS026171
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: