Provider Demographics
NPI:1316355472
Name:PETERSON, LYNN (RPH)
Entity type:Individual
Prefix:MR
First Name:LYNN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 58TH ST W
Mailing Address - Street 2:STE 239
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-7217
Mailing Address - Country:US
Mailing Address - Phone:701-774-3923
Mailing Address - Fax:701-774-8731
Practice Address - Street 1:300 11TH ST W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5159
Practice Address - Country:US
Practice Address - Phone:701-774-3923
Practice Address - Fax:701-774-8731
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist