Provider Demographics
NPI:1386704476
Name:PETERSON, JUDY A (RPH, MS)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RPH, MS
Other - Prefix:MRS
Other - First Name:JUDY
Other - Middle Name:LOUTHER
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH, MS
Mailing Address - Street 1:145 SEEWALD RD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5005
Mailing Address - Country:US
Mailing Address - Phone:830-230-5524
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-7396
Practice Address - Fax:210-292-6748
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX168991835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology