Provider Demographics
NPI:1063825115
Name:MAURETTA, PETER (RPH)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MAURETTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NORTH HIGWAY 29
Mailing Address - Street 2:
Mailing Address - City:HOGANSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30230
Mailing Address - Country:US
Mailing Address - Phone:706-637-0881
Mailing Address - Fax:706-637-8709
Practice Address - Street 1:200 NORTH HIGWAY 29
Practice Address - Street 2:
Practice Address - City:HOGANSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30230
Practice Address - Country:US
Practice Address - Phone:706-637-0881
Practice Address - Fax:706-637-8709
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051535325OtherDRIVER'S LICNESE
GARPH023195OtherPHARMACIST LICENSE