Healthcare Provider Details

I. General information

NPI: 1619958279
Provider Name (Legal Business Name): VERNON ELLIOTT PETERSON RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ERICA ERIN SCHROEDER PHARMD

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 3RD AVE
MOUNTAIN LAKE MN
56159-1587
US

IV. Provider business mailing address

1007 3RD AVE PO BOX 310
MOUNTAIN LAKE MN
56159-0310
US

V. Phone/Fax

Practice location:
  • Phone: 507-427-2707
  • Fax: 507-427-2328
Mailing address:
  • Phone: 507-427-2707
  • Fax: 507-427-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number267371
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number111199
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: