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General NPI Number Information
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NPI Number | 1720374903
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Entity Type | Individual
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Provider Name | JAN MARIE PETERSON PHARMD
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Gender | Female
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Dates
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Enumeration Date | 06/25/2011
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Last Update Date | 06/25/2011
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Provider Practice Location Address
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Address Line | 5537 W BROADWAY AVE T-0003
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City | CRYSTAL
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State | MN
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Zip | 55428-3507
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Country | US
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Telephone | 763-533-1651
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Fax | 763-252-2005
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Provider Business Mailing Address
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Address Line | 5537 W BROADWAY AVE T-0003
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City | CRYSTAL
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State | MN
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Zip | 55428-3507
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Country | US
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Telephone | 763-533-1651
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Fax | 763-252-2005
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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 | 118191
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License Number State | MN
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