Healthcare Provider Details

I. General information

NPI: 1457564916
Provider Name (Legal Business Name): MARY BETH PETERSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HY-VEE DRUGSTORE #7026 2001 BLAIRS FERRY RD NE
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

1188 QUINN AVE
AURORA IA
50607-9708
US

V. Phone/Fax

Practice location:
  • Phone: 319-393-0561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14812
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: