Provider Demographics
NPI:1194495051
Name:PETERSON'S SUPERMARKET, INC
Entity type:Organization
Organization Name:PETERSON'S SUPERMARKET, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF SUPERMARKET
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-537-2048
Mailing Address - Street 1:718 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-2347
Mailing Address - Country:US
Mailing Address - Phone:308-537-2048
Mailing Address - Fax:
Practice Address - Street 1:718 4TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-2347
Practice Address - Country:US
Practice Address - Phone:308-537-2048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy