MEDICARE: NOLAND PETERDY PHARMD, JD, MBA

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	39210	WA

General Provider Information

NPI Number	:	1841627601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOLAND PETERDY PHARMD, JD, MBA

Provider Business Mailing Address
First Line	:	BOX 727
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1423 N MOLTER 727
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019
Country	:	US
Telephone Number	:	509-220-7512
Fax Number	:

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

Provider Enumeration Date	:	10/10/2013
Last Update Date	:	10/10/2013

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