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General NPI Number Information
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NPI Number | 1407239338
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Entity Type | Individual
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Provider Name | LISA PETERSEN
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Gender | Female
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Dates
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Enumeration Date | 07/09/2015
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Last Update Date | 07/09/2015
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Provider Practice Location Address
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Address Line | 213 CALUMET AVE SW
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City | DE SMET
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State | SD
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Zip | 57231-2161
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Country | US
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Telephone | 605-854-9033
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Fax | 605-854-9114
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Provider Business Mailing Address
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Address Line | 307 4TH ST SW
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City | DE SMET
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State | SD
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Zip | 57231-2230
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Country | US
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Telephone | 605-854-9033
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Fax | 605-854-9114
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5091
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License Number State | SD
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