Organization
MICHAEL T PETERS
Active
Organization
MICHAEL T PETERS
Active
Other names
COUNTRY CLUB DRUG STORE
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL PETERS (OWNER)
(209) 473-1762
Entity
Organization
Contact information
Practice address
1919 VISTA DEL LAGO DR, STE 6, VALLEY SPRINGS, CA 95252-9294
(209) 772-1633
(209) 772-1676
Mailing address
7302 LARKSPUR LN, STOCKTON, CA 95207-1629
(209) 473-1762
(209) 473-2013
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
PHY49019
CA
3336C0004X
Compounding Pharmacy
—
—
3336M0002X
Mail Order Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5631191
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
08/04/2008
Last updated
06/29/2009
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