Provider Demographics
NPI:1689785537
Name:PETERS, CORIN ELLEN (CPHT)
Entity Type:Individual
Prefix:
First Name:CORIN
Middle Name:ELLEN
Last Name:PETERS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9044
Mailing Address - Country:US
Mailing Address - Phone:269-673-6826
Mailing Address - Fax:
Practice Address - Street 1:115 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1301
Practice Address - Country:US
Practice Address - Phone:269-673-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2801-0104-0351-768183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
2801-0104-0351-768OtherPHARMACY TECHNICIAN CERT