Healthcare Provider Details

I. General information

NPI: 1922219641
Provider Name (Legal Business Name): JAMES ROBERT PETERSEN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 UNIVERSITY AVE
WATERLOO IA
50701-5640
US

IV. Provider business mailing address

1109 BOBBI LN
WATERLOO IA
50701-3230
US

V. Phone/Fax

Practice location:
  • Phone: 319-236-1786
  • Fax: 319-236-0074
Mailing address:
  • Phone: 319-236-1786
  • Fax: 319-236-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14811
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberIA14811
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: