Provider Demographics
NPI:1780673905
Name:PETO PETERSON, AMANDA JANE (RPH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:PETO PETERSON
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 1:17760 BRITTANY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-5533
Mailing Address - Country:US
Mailing Address - Phone:440-543-9334
Mailing Address - Fax:
Practice Address - Street 1:2181 E AURORA RD
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-1974
Practice Address - Country:US
Practice Address - Phone:330-405-8080
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-21120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist