Provider Demographics
NPI:1275120180
Name:PETERSON, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PETERSON
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 1:50 PIGEON HILL RD
Mailing Address - Street 2:
Mailing Address - City:MECHANIC FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04256-5726
Mailing Address - Country:US
Mailing Address - Phone:207-998-2650
Mailing Address - Fax:207-998-2670
Practice Address - Street 1:50 PIGEON HILL RD
Practice Address - Street 2:
Practice Address - City:MECHANIC FALLS
Practice Address - State:ME
Practice Address - Zip Code:04256-5726
Practice Address - Country:US
Practice Address - Phone:207-998-2650
Practice Address - Fax:207-998-2670
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist