Provider Demographics
NPI:1568757029
Name:PETERCUSKIE, JANE
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:
Last Name:PETERCUSKIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO BEND
Mailing Address - State:VT
Mailing Address - Zip Code:05842
Mailing Address - Country:US
Mailing Address - Phone:802-533-9294
Mailing Address - Fax:
Practice Address - Street 1:82 ROUTE 15 WEST
Practice Address - Street 2:
Practice Address - City:HARDWICK
Practice Address - State:VT
Practice Address - Zip Code:05843
Practice Address - Country:US
Practice Address - Phone:802-472-6961
Practice Address - Fax:802-472-8207
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT00003461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT183500000XOtherPHARMACIST