Basic Information
| Provider Information | |||||||||
| NPI: | 1013590330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPHT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3710 BROADWAY ST # 342 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623052822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176539537 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1005 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172232263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2021 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | 049214411 | IL | Y | Pharmacy Service Providers | Pharmacy Technician |
ID Information
| ID | Type | State | Issuer | Description | 10015096 | 01 | PHARMACY TECHNICIAN CERTIFICATION | OTHER | 049214411 | 01 | IL | PHARMACY TECHNICIAN LICENSE | OTHER |