=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518504984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETERSEN INVESTMENTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2019
-----------------------------------------------------
Last Update Date | 02/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12119 NE 99TH ST STE 2030
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-217-4250
-----------------------------------------------------
Fax | 360-230-1919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12119 NE 99TH ST STE 2030
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-217-4250
-----------------------------------------------------
Fax | 360-230-1919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | KRISTOPHER PETERSEN
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 360-261-9040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------