MEDICARE: AMANDA JANE PETO PETERSON RPH

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	03-2-21120	OH

General Provider Information

NPI Number	:	1780673905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JANE PETO PETERSON RPH

Provider Business Mailing Address
First Line	:	17760 BRITTANY WOODS DR
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44023-5533
Country	:	US
Telephone Number	:	440-543-9334
Fax Number	:

Provider Business Practice Location Address
First Line	:	2181 E AURORA RD
Second Line	:
City	:	TWINSBURG
State	:	OH
Zip	:	44087-1974
Country	:	US
Telephone Number	:	330-405-8080
Fax Number	:

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

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	07/08/2007

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