NPIMap

Organization Active NPI

Michael T Peters

  • Community/Retail Pharmacy
  • Valley Springs, CA
National Provider Identifier
1720244353
Registry record updated Jun 29, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHY49019 Issued in CA
Legal business name
MICHAEL T PETERS
Doing business as
COUNTRY CLUB DRUG STORE
Practice address
1919 Vista del Lago Dr
Ste 6
Valley Springs, CA 95252-9294
Phone
(209) 772-1633
Fax
(209) 772-1676
NPI assigned
Aug 4, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michael PetersNPI 1023755634
Title
Owner
Phone
(209) 473-1762

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X PHY49019 CA Primary
Compounding Pharmacy 3336C0004X
Mail Order Pharmacy 3336M0002X

Addresses

Primary practice location

1919 Vista del Lago Dr
Ste 6
Valley Springs, CA 95252-9294

Mailing address

7302 Larkspur LN
Stockton, CA 95207-1629
Phone (209) 473-1762

Other identifiers 1

IdentifierTypeStateIssuer
5631191OtherNCPDP PROVIDER IDENTIFICATION NUMBER

Other names 1

  • COUNTRY CLUB DRUG STORE Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Country Club Drug Store2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1919 Vista del Lago Dr
Ste 6
Valley Springs, CA 95252
Phone (209) 772-1633

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1217808000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1246233600000",
    "number": "1720244353",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7302 LARKSPUR LN",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952071629",
            "telephone_number": "209-473-1762",
            "fax_number": "209-473-2013"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1919 VISTA DEL LAGO DR",
            "address_2": "STE 6",
            "city": "VALLEY SPRINGS",
            "state": "CA",
            "postal_code": "952529294",
            "telephone_number": "209-772-1633",
            "fax_number": "209-772-1676"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MICHAEL T PETERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-04",
        "last_updated": "2009-06-29",
        "status": "A",
        "authorized_official_last_name": "PETERS",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "209-473-1762"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CA",
            "license": "PHY49019",
            "primary": true
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336M0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Mail Order Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "5631191",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "COUNTRY CLUB DRUG STORE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Valley Springs, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 29, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.