Provider Demographics
NPI:1295920544
Name:PETERSON, DAVID M (PHARMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 WAKARA WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1244
Mailing Address - Country:US
Mailing Address - Phone:801-585-5998
Mailing Address - Fax:
Practice Address - Street 1:421 WAKARA WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1244
Practice Address - Country:US
Practice Address - Phone:801-585-5998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT353870-17011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy