Provider Demographics
NPI:1386070647
Name:PETERSON, DAVID MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
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 1:1200 W GOLD ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2110
Mailing Address - Country:US
Mailing Address - Phone:406-494-1075
Mailing Address - Fax:
Practice Address - Street 1:1200 W GOLD ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2110
Practice Address - Country:US
Practice Address - Phone:406-494-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-2883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPHA-PHA-LIC-2883OtherPHARMACY LIC #