Provider Demographics
NPI:1861750630
Name:PETERSON, JOHN D (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
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:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0503
Mailing Address - Country:US
Mailing Address - Phone:715-349-2221
Mailing Address - Fax:715-349-7350
Practice Address - Street 1:24106 STATE ROAD 35 70
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-8006
Practice Address - Country:US
Practice Address - Phone:715-349-2221
Practice Address - Fax:715-349-7350
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16207-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist