Provider Demographics
NPI:1447495643
Name:PETERKA, SHAWN RENEE (PHARM D)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:RENEE
Last Name:PETERKA
Suffix:
Gender:F
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 1:1734 MALL DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3839
Mailing Address - Country:US
Mailing Address - Phone:218-727-3477
Mailing Address - Fax:218-727-2839
Practice Address - Street 1:1734 MALL DRIVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811
Practice Address - Country:US
Practice Address - Phone:218-727-3477
Practice Address - Fax:218-727-2839
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119501183500000X
WI15334040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist