Basic Information
| Provider Information | |||||||||
| NPI: | 1386704476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH., M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | JUDY | ||||||||
| OtherMiddleName: | LOUTHER | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.PH, M.S. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 145 SEEWALD RD | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780065005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302305524 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 BERGQUIST DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LACKLAND AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782369908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102927396 | ||||||||
| FaxNumber: | 2102926748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835X0200X | 16899 | TX | Y | Pharmacy Service Providers | Pharmacist | Oncology |
No ID Information.