MEDICARE: MR. JOHN C PETERSON PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	16303	WI

General Provider Information

NPI Number	:	1275149718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN C PETERSON PHARMACIST

Provider Business Mailing Address
First Line	:	632 ETHAN TER
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-2244
Country	:	US
Telephone Number	:	608-482-3079
Fax Number	:

Provider Business Practice Location Address
First Line	:	1602 HIDDEN HILL DR
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-7970
Country	:	US
Telephone Number	:	608-848-5956
Fax Number	:	608-848-5956

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	01/05/2021

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Directions to “ MR. JOHN C PETERSON PHARMACIST” Practice Location

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