Provider Demographics
NPI:1619958279
Name:PETERSON, VERNON ELLIOTT (RPH)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:ELLIOTT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56618 LAKESHORE DR
Mailing Address - Street 2:PO BOX 310
Mailing Address - City:MOUNTAIN LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56159-2329
Mailing Address - Country:US
Mailing Address - Phone:507-427-3207
Mailing Address - Fax:
Practice Address - Street 1:1007 3RD AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKE
Practice Address - State:MN
Practice Address - Zip Code:56159-1587
Practice Address - Country:US
Practice Address - Phone:507-427-2707
Practice Address - Fax:507-427-2328
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111199-8183500000X
SD3595183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111199-8OtherMN PHARMACIST LICENSE
MN7300001030Medicare NSC