Provider Demographics
NPI:1962169474
Name:PETERSON, ERIC D (RPH)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:D
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 1:716 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-1286
Mailing Address - Country:US
Mailing Address - Phone:620-364-3388
Mailing Address - Fax:620-364-3381
Practice Address - Street 1:716 N 4TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-1286
Practice Address - Country:US
Practice Address - Phone:620-364-3388
Practice Address - Fax:620-364-3381
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-11372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist