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General NPI Number Information
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NPI Number | 1194495051
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Entity Type | Organization
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Legal Business Name | PETERSON'S SUPERMARKET, INC
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Dates
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Enumeration Date | 09/14/2021
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Last Update Date | 09/15/2021
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Provider Practice Location Address
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Address Line | 718 4TH ST
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City | GOTHENBURG
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State | NE
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Zip | 69138-2347
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Country | US
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Telephone | 308-537-2048
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Fax |
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Provider Business Mailing Address
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Address Line | 718 4TH ST
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City | GOTHENBURG
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State | NE
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Zip | 69138-2347
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Country | US
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Telephone | 308-537-2048
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Fax |
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Authorized Official
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Title or Position | MANAGER OF SUPERMARKET
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Name | MICHAEL PETERSON
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Credential |
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Telephone | 308-537-2048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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