Healthcare Provider Details

I. General information

NPI: 1912116054
Provider Name (Legal Business Name): PETOSKEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N 2ND AVE W SUITE 200
DULUTH MN
55802-1911
US

IV. Provider business mailing address

109 N 2ND AVE W SUITE 200
DULUTH MN
55802-1911
US

V. Phone/Fax

Practice location:
  • Phone: 218-733-6800
  • Fax: 218-740-4048
Mailing address:
  • Phone: 218-733-6800
  • Fax: 218-740-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number263020
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number263020
License Number StateMN

VIII. Authorized Official

Name: CHARLES KORSCH
Title or Position: CEO
Credential:
Phone: 218-733-6800