Provider Demographics
NPI:1043942865
Name:PETERSON, JUSTIN ROBERT (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3938 OSAGE BEACH PKWY
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-2146
Mailing Address - Country:US
Mailing Address - Phone:573-348-5081
Mailing Address - Fax:
Practice Address - Street 1:3938 OSAGE BEACH PKWY
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-2146
Practice Address - Country:US
Practice Address - Phone:573-348-5081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022023819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist