Healthcare Provider Details

I. General information

NPI: 1386841591
Provider Name (Legal Business Name): MARK DEWITT PETERS RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

815 N.W. 451 ROAD
CLINTON MO
64735
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-5511
  • Fax: 660-885-6279
Mailing address:
  • Phone: 660-890-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number043372
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: