Provider Demographics
NPI:1225338239
Name:PEACOCK, BRENT H
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:H
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11124
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1124
Mailing Address - Country:US
Mailing Address - Phone:307-734-1917
Mailing Address - Fax:
Practice Address - Street 1:1425 S HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-4330
Practice Address - Country:US
Practice Address - Phone:307-733-8746
Practice Address - Fax:307-733-8824
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2773183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist