Healthcare Provider Details

I. General information

NPI: 1831194703
Provider Name (Legal Business Name): DON PETERSON DRUG CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 MAIN ST
CASSVILLE MO
65625-1421
US

IV. Provider business mailing address

705 MAIN ST
CASSVILLE MO
65625-1421
US

V. Phone/Fax

Practice location:
  • Phone: 417-847-2315
  • Fax: 417-847-5258
Mailing address:
  • Phone: 417-847-2315
  • Fax: 417-847-5258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number200300001338
License Number StateMO

VIII. Authorized Official

Name: MR. CONG DANG
Title or Position: OWNER
Credential: RPH
Phone: 417-847-2315