MEDICARE: KEVIN PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	29908	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2152835	OTHER		PK

General Provider Information

NPI Number	:	1427443522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN PETERSON

Provider Business Mailing Address
First Line	:	2503 CARTWRIGHT RD
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-2606
Country	:	US
Telephone Number	:	281-969-7940
Fax Number	:	832-987-1226

Provider Business Practice Location Address
First Line	:	2503 CARTWRIGHT RD
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-2606
Country	:	US
Telephone Number	:	281-969-7940
Fax Number	:	832-987-1226

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN PETERSON
Credential	:
Telephone Number	:	281-914-7154

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	07/20/2015

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Directions to “KEVIN PETERSON ” Practice Location

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