Provider Demographics
NPI:1487229019
Name:PETERS, DALE JUSTIN
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:JUSTIN
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 1:401 E IVY RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2649
Mailing Address - Country:US
Mailing Address - Phone:605-940-4620
Mailing Address - Fax:
Practice Address - Street 1:401 E IVY RD UNIT 3
Practice Address - Street 2:
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-2649
Practice Address - Country:US
Practice Address - Phone:605-940-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist