Provider Demographics
NPI:1174712434
Name:PETERSON, KEVIN RICHARD (PHARMD RPH)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RICHARD
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 1:2324 S 156TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2511
Mailing Address - Country:US
Mailing Address - Phone:402-330-5482
Mailing Address - Fax:402-330-2697
Practice Address - Street 1:2324 S 156TH CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2511
Practice Address - Country:US
Practice Address - Phone:402-330-5482
Practice Address - Fax:402-330-2697
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE11834OtherPHARMACY LICENSE