Provider Demographics
NPI:1285735241
Name:TOMSHACK, PETER A (RPH)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:TOMSHACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NORTH MAIN
Mailing Address - Street 2:PO BOX 635
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631
Mailing Address - Country:US
Mailing Address - Phone:231-734-3811
Mailing Address - Fax:231-734-6170
Practice Address - Street 1:107 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:EVART
Practice Address - State:MI
Practice Address - Zip Code:49631
Practice Address - Country:US
Practice Address - Phone:231-734-3811
Practice Address - Fax:231-734-6170
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020377183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F71003OtherMICHIGAN BCBS DME PROVIDE
2315477OtherNABP
MI4818929Medicaid
2315477OtherNABP