MEDICARE: CANNON FALLS SNYDER PHCY INC

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	2608604	MN

General Provider Information

NPI Number	:	1841290921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANNON FALLS SNYDER PHCY INC

Provider Business Mailing Address
First Line	:	31265 COUNTY 24 BLVD
Second Line	:
City	:	CANNON FALLS
State	:	MN
Zip	:	55009-4071
Country	:	US
Telephone Number	:	507-263-4741
Fax Number	:	507-263-0740

Provider Business Practice Location Address
First Line	:	31265 COUNTY 24 BLVD
Second Line	:
City	:	CANNON FALLS
State	:	MN
Zip	:	55009-4071
Country	:	US
Telephone Number	:	507-263-4741
Fax Number	:	507-263-0740

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN CLAYTON PETERSON
Credential	:	PHARMD
Telephone Number	:	507-263-4741

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/22/2020

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