Provider Demographics
NPI:1972936557
Name:PETERSON, RYAN (PHARM D)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:ALBERTON
Mailing Address - State:MT
Mailing Address - Zip Code:59820-9619
Mailing Address - Country:US
Mailing Address - Phone:503-507-5881
Mailing Address - Fax:
Practice Address - Street 1:1766 COFFEEN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5710
Practice Address - Country:US
Practice Address - Phone:307-674-1936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist