=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609964816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PECK GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 05/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4384 E. PLEASANT VALLEY BLVD. STE 1
-----------------------------------------------------
City | TIPTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-684-7979
-----------------------------------------------------
Fax | 814-684-7647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 40
-----------------------------------------------------
City | TIPTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-684-7979
-----------------------------------------------------
Fax | 814-684-7647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHARMACIST
-----------------------------------------------------
Name | CHARLES C PECK
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 814-684-7979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP415132L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------