Provider Demographics
NPI:1639597206
Name:PEIPPO, MARK FREDERICK (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:FREDERICK
Last Name:PEIPPO
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 1:563 W FM 120
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-9039
Mailing Address - Country:US
Mailing Address - Phone:903-786-2006
Mailing Address - Fax:903-355-2361
Practice Address - Street 1:563 W FM 120
Practice Address - Street 2:
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076-9039
Practice Address - Country:US
Practice Address - Phone:903-786-2006
Practice Address - Fax:903-355-2361
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146257Medicaid