Healthcare Provider Details

I. General information

NPI: 1255252078
Provider Name (Legal Business Name): MARK C PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAPLE ST
WACONIA MN
55387-1791
US

IV. Provider business mailing address

500 S MAPLE ST
WACONIA MN
55387-1791
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2191
  • Fax:
Mailing address:
  • Phone: 952-442-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number124999
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: