Healthcare Provider Details

I. General information

NPI: 1841290921
Provider Name (Legal Business Name): CANNON FALLS SNYDER PHCY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31265 COUNTY 24 BLVD
CANNON FALLS MN
55009-4071
US

IV. Provider business mailing address

31265 COUNTY 24 BLVD
CANNON FALLS MN
55009-4071
US

V. Phone/Fax

Practice location:
  • Phone: 507-263-4741
  • Fax: 507-263-0740
Mailing address:
  • Phone: 507-263-4741
  • Fax: 507-263-0740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2608604
License Number StateMN

VIII. Authorized Official

Name: JOHN CLAYTON PETERSON
Title or Position: OWNER
Credential: PHARMD
Phone: 507-263-4741