=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205240116
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ERNEST PECK PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 06/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7227 PONTIAC CIR
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-9454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-474-5071
-----------------------------------------------------
Fax | 952-474-3079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7227 PONTIAC CIR
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-9454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-474-5071
-----------------------------------------------------
Fax | 952-474-3079
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 110629
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------