Basic Information
| Provider Information | |||||||||
| NPI: | 1780673905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETO PETERSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17760 BRITTANY WOODS DR | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440235533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405439334 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2181 E AURORA RD | ||||||||
| Address2: | |||||||||
| City: | TWINSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440871974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304058080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03-2-21120 | OH | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.