=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780729848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETERSON PHARMACY INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 4TH ST
-----------------------------------------------------
City | DASSEL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55325-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-275-3052
-----------------------------------------------------
Fax | 320-275-2591
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 4TH ST PO BOX 280
-----------------------------------------------------
City | DASSEL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55325-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-275-3052
-----------------------------------------------------
Fax | 320-275-2591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MYRON D SYLVESTER
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 320-275-3052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 260192
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------