Provider Demographics
NPI:1619258639
Name:PETERSON, GARY PHILLIP (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:PHILLIP
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 1:2404 S PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-8231
Mailing Address - Country:US
Mailing Address - Phone:815-332-3256
Mailing Address - Fax:815-332-4180
Practice Address - Street 1:2404 S PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-8231
Practice Address - Country:US
Practice Address - Phone:815-332-3256
Practice Address - Fax:815-332-4180
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist