Provider Demographics
NPI:1992379176
Name:PECK, NATHAN HAROLD
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:HAROLD
Last Name:PECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 HWY 16 TARGET-T0620
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-779-5780
Mailing Address - Fax:
Practice Address - Street 1:9400 HWY 16 TARGET-T0620
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650
Practice Address - Country:US
Practice Address - Phone:608-779-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124628183500000X
WI20058-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist