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NPI Code Detail

MEDICARE: MRS. CONNIE MARIE PETERSON RPH

MEDICARE: MRS. CONNIE MARIE PETERSON RPH
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
1183500000XPharmacist13816LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
113816OTHERLABOARD OF PHARMACY

General Provider Information

NPI Number : 1831190131
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. CONNIE MARIE PETERSON RPH
Provider Business Mailing Address
First Line : 2310 COULEE CROSSING RD
Second Line :
City : WOODWORTH
State : LA
Zip : 71485-9732
Country : US
Telephone Number : 318-442-0229
Fax Number :
Provider Business Practice Location Address
First Line : 2351 VANDENBURG DR
Second Line :
City : ALEXANDRIA
State : LA
Zip : 71303-5609
Country : US
Telephone Number : 318-483-7336
Fax Number : 318-483-7088
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/09/2005
Last Update Date : 07/08/2007

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