Healthcare Provider Details

I. General information

NPI: 1972643237
Provider Name (Legal Business Name): PATRICIA PETERSON R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 MICHIGAN AVE
OROFINO ID
83544-2625
US

IV. Provider business mailing address

22500 ANGEL RIDGE RD
PECK ID
83545-8059
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-5727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5043
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: