Provider Demographics
NPI:1831194703
Name:DON PETERSON DRUG CO
Entity type:Organization
Organization Name:DON PETERSON DRUG CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-847-2315
Mailing Address - Street 1:705 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CASSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65625-1421
Mailing Address - Country:US
Mailing Address - Phone:417-847-2315
Mailing Address - Fax:417-847-5258
Practice Address - Street 1:705 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1421
Practice Address - Country:US
Practice Address - Phone:417-847-2315
Practice Address - Fax:417-847-5258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2015-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200300001338333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600094205Medicaid
MO620094201Medicaid
MO200300001338OtherMO LIC
MO0592950001Medicare PIN
MO0592950001Medicare ID - Type Unspecified