=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871558395
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY MARTIN PECK RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2006
-----------------------------------------------------
Last Update Date | 09/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2195 STATE ROUTE 442
-----------------------------------------------------
City | MUNCY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17756-7600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-546-8272
-----------------------------------------------------
Fax | 570-546-5224
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 346 DEWALD LN
-----------------------------------------------------
City | HUGHESVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17737-8680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-584-5453
-----------------------------------------------------
Fax | 570-584-5453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP027619L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------