Provider Demographics
NPI:1780729848
Name:PETERSON PHARMACY INCORPORATED
Entity type:Organization
Organization Name:PETERSON PHARMACY INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:D
Authorized Official - Last Name:SYLVESTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:320-275-3052
Mailing Address - Street 1:440 4TH ST
Mailing Address - Street 2:PO BOX 280
Mailing Address - City:DASSEL
Mailing Address - State:MN
Mailing Address - Zip Code:55325-4543
Mailing Address - Country:US
Mailing Address - Phone:320-275-3052
Mailing Address - Fax:320-275-2591
Practice Address - Street 1:440 4TH ST
Practice Address - Street 2:
Practice Address - City:DASSEL
Practice Address - State:MN
Practice Address - Zip Code:55325-4543
Practice Address - Country:US
Practice Address - Phone:320-275-3052
Practice Address - Fax:320-275-2591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2601923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2404399OtherNCPDP
MN260192OtherSTATE LICENSE NUMBER
MN840858100Medicaid
MNAP3012464OtherDEA NUMBER
MN2404399OtherNCPDP