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General NPI Number Information
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NPI Number | 1407272065
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Entity Type | Individual
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Provider Name | CHAX BRANDON PETERSON PHARM. D.
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Gender | Male
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Dates
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Enumeration Date | 03/06/2014
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Last Update Date | 03/06/2014
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Provider Practice Location Address
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Address Line | 8093 N CORNERSTONE DR
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City | HAYDEN
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State | ID
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Zip | 83835-8753
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Country | US
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Telephone | 208-762-9355
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Fax | 208-762-9198
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Provider Business Mailing Address
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Address Line | 16654 N MORGAN LN
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City | HAYDEN
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State | ID
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Zip | 83835-5015
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Country | US
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Telephone | 208-651-6195
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Fax |
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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 | P5271
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License Number State | ID
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