Provider Demographics
NPI:1003190315
Name:MATHIS, WALTER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:MATHIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 SE GOODFELLOW ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3016
Mailing Address - Country:US
Mailing Address - Phone:541-889-6288
Mailing Address - Fax:541-889-5675
Practice Address - Street 1:65 SE GOODFELLOW ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3016
Practice Address - Country:US
Practice Address - Phone:541-889-6288
Practice Address - Fax:541-889-5675
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0012637183500000X
IDP6524183500000X
MT5302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist