Provider Demographics
NPI:1134477136
Name:PETERS, MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 65TH ST APT 54
Mailing Address - Street 2:
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50324-1063
Mailing Address - Country:US
Mailing Address - Phone:507-236-1913
Mailing Address - Fax:
Practice Address - Street 1:6200 MERLE HAY RD
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1225
Practice Address - Country:US
Practice Address - Phone:515-331-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist