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General NPI Number Information
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NPI Number | 1912116054
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Entity Type | Organization
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Legal Business Name | PETOSKEY, INC.
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 11/30/2009
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Provider Practice Location Address
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Address Line | 109 N 2ND AVE W SUITE 200
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City | DULUTH
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State | MN
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Zip | 55802-1911
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Country | US
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Telephone | 218-733-6800
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Fax | 218-740-4048
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Provider Business Mailing Address
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Address Line | 109 N 2ND AVE W SUITE 200
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City | DULUTH
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State | MN
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Zip | 55802-1911
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Country | US
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Telephone | 218-733-6800
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Fax | 218-740-4048
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Authorized Official
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Title or Position | CEO
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Name | CHARLES KORSCH
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Credential |
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Telephone | 218-733-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 263020
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 263020
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License Number State | MN
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