Provider Demographics
NPI:1386019032
Name:DANIEL, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DANIEL
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 1:47115 W WAYFORD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4803
Mailing Address - Country:US
Mailing Address - Phone:586-344-6654
Mailing Address - Fax:
Practice Address - Street 1:31720 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4554
Practice Address - Country:US
Practice Address - Phone:586-415-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302037521OtherBOARD OF PHARMACY