Provider Demographics
NPI:1356379895
Name:PETERS, LANNY R
Entity type:Individual
Prefix:
First Name:LANNY
Middle Name:R
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:PO BOX 314
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:TN
Mailing Address - Zip Code:37658-0314
Mailing Address - Country:US
Mailing Address - Phone:423-725-4175
Mailing Address - Fax:
Practice Address - Street 1:339 HIGHWAY 321
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:TN
Practice Address - Zip Code:37658-3277
Practice Address - Country:US
Practice Address - Phone:423-725-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4433859Medicaid
TN4433859Medicaid