Healthcare Provider Details

I. General information

NPI: 1720244353
Provider Name (Legal Business Name): MICHAEL T PETERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 VISTA DEL LAGO DR STE 6
VALLEY SPRINGS CA
95252-9294
US

IV. Provider business mailing address

7302 LARKSPUR LN
STOCKTON CA
95207-1629
US

V. Phone/Fax

Practice location:
  • Phone: 209-772-1633
  • Fax: 209-772-1676
Mailing address:
  • Phone: 209-473-1762
  • Fax: 209-473-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY49019
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL PETERS
Title or Position: OWNER
Credential:
Phone: 209-473-1762