Provider Demographics
NPI:1194080135
Name:PETERSEN, STEPHANIE JEAN (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JEAN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 GROVE CIR N
Mailing Address - Street 2:T2223
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4469
Mailing Address - Country:US
Mailing Address - Phone:763-447-2507
Mailing Address - Fax:
Practice Address - Street 1:15300 GROVE CIR N
Practice Address - Street 2:T2223
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4469
Practice Address - Country:US
Practice Address - Phone:763-447-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist