MEDICARE: PETER KOMU

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	183500000X	Pharmacist	83661	CA

General Provider Information

NPI Number	:	1467054890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER KOMU

Provider Business Mailing Address
First Line	:	1216 LITCHFIELD LN
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-8226
Country	:	US
Telephone Number	:	646-644-5236
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 S MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4806
Country	:	US
Telephone Number	:	707-964-1848
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	02/03/2023

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Directions to “ PETER KOMU ” Practice Location

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