Provider Demographics
NPI:1891878260
Name:TA, PETER T (PHARMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:TA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9893 N BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-4247
Mailing Address - Country:US
Mailing Address - Phone:559-433-9633
Mailing Address - Fax:
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2941
Practice Address - Country:US
Practice Address - Phone:559-448-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist