Healthcare Provider Details

I. General information

NPI: 1720767585
Provider Name (Legal Business Name): BAILEY PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 26TH ST E
WILLISTON ND
58801-3046
US

IV. Provider business mailing address

13482 79TH ST NW
ALAMO ND
58830-9569
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-4181
  • Fax: 701-572-0921
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH6494
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: