Basic Information
| Provider Information | |||||||||
| NPI: | 1376203455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SAVANNAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARM D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 SAINT CECIL | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731602536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057602900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15951 LITTLE AXE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052929530 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2021 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 19341 | OK | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.