Provider Demographics
NPI:1902248040
Name:PETERSON, ANTHONY LEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 N 12TH STREET
Mailing Address - Street 2:PO BOX 388
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851
Mailing Address - Country:US
Mailing Address - Phone:208-686-5081
Mailing Address - Fax:208-688-6611
Practice Address - Street 1:427 N 12TH STREET
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-5081
Practice Address - Fax:208-688-6611
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist