Provider Demographics
NPI:1790008647
Name:PETERS, JAMES ROBERT
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 N MILLSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4322
Mailing Address - Country:US
Mailing Address - Phone:815-385-1457
Mailing Address - Fax:
Practice Address - Street 1:400 E ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1334
Practice Address - Country:US
Practice Address - Phone:847-740-3687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-07
Last Update Date:2010-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051027686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist