Provider Demographics
NPI:1255659728
Name:STAYER, PETER R (RPH)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:R
Last Name:STAYER
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 1:32950 KNAPP AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-8104
Mailing Address - Country:US
Mailing Address - Phone:586-268-4145
Mailing Address - Fax:
Practice Address - Street 1:26696 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-1144
Practice Address - Country:US
Practice Address - Phone:586-755-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-08
Last Update Date:2010-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist