MEDICARE: LISA PETERSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5091	SD

General Provider Information

NPI Number	:	1407239338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PETERSEN

Provider Business Mailing Address
First Line	:	307 4TH ST SW
Second Line	:
City	:	DE SMET
State	:	SD
Zip	:	57231-2230
Country	:	US
Telephone Number	:	605-854-9033
Fax Number	:	605-854-9114

Provider Business Practice Location Address
First Line	:	213 CALUMET AVE SW
Second Line	:
City	:	DE SMET
State	:	SD
Zip	:	57231-2161
Country	:	US
Telephone Number	:	605-854-9033
Fax Number	:	605-854-9114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	07/09/2015

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Directions to “ LISA PETERSEN ” Practice Location

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