Healthcare Provider Details

I. General information

NPI: 1144227448
Provider Name (Legal Business Name): NICOLE MARIE PETERSEN PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 N LINDBERGH BLVD SCHNUCKS PHARMACY
FLORISSANT MO
63031-7107
US

IV. Provider business mailing address

6625 ALAMO AVE APT 1E
SAINT LOUIS MO
63105-3129
US

V. Phone/Fax

Practice location:
  • Phone: 314-921-7345
  • Fax: 314-921-7346
Mailing address:
  • Phone: 314-446-8555
  • Fax: 314-446-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2003023575
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: