Provider Demographics
NPI:1619246600
Name:PETERS, MICHELLE DAWN (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:PETERS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-1204
Mailing Address - Country:US
Mailing Address - Phone:814-664-2053
Mailing Address - Fax:814-664-9623
Practice Address - Street 1:434 N CENTER ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1204
Practice Address - Country:US
Practice Address - Phone:814-664-2053
Practice Address - Fax:814-664-9623
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP044200L183500000X
NY053093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY053093OtherPHARMACIST LISCENSE
PARP044200LOtherPHARMACIST LICENSE