Provider Demographics
NPI:1235437351
Name:PETERS, WAYNE B
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:B
Last Name:PETERS
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 1:6019 FOX GROVE PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-6540
Mailing Address - Country:US
Mailing Address - Phone:585-329-4379
Mailing Address - Fax:
Practice Address - Street 1:151 PIKE VIEW DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-7340
Practice Address - Country:US
Practice Address - Phone:804-594-0185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist