Active NPI
Kenneth R Petersen, RPH
- Pharmacist
- Lacey, WA
National Provider Identifier
1972879401
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- PH00019664
- Practice address
- 5500 Martin Way E
Lacey, WA 98516-6326 - Phone
- (360) 456-4057
- NPI assigned
- Mar 29, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | PH00019664 | WA | Primary |
Addresses
Primary practice location
5500 Martin Way E
Lacey, WA 98516-6326
Mailing address
5500 Martin Way S.E.
Lacey, WA 98516
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PH00019664 | WA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1332979200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1332979200000",
"number": "1972879401",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5500 MARTIN WAY S.E.",
"city": "LACEY",
"state": "WA",
"postal_code": "98516"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5500 MARTIN WAY E",
"city": "LACEY",
"state": "WA",
"postal_code": "985166326",
"telephone_number": "360-456-4057"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "KENNETH",
"middle_name": "R",
"name_prefix": "Mr.",
"credential": "RPH",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-03-29",
"last_updated": "2012-03-29",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "WA",
"license": "PH00019664",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lacey, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.