Provider Demographics
NPI:1023018025
Name:WALTERS, MARK WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:WALTERS
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 1:11405 TOWN LINE RD
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-8149
Mailing Address - Country:US
Mailing Address - Phone:218-263-3553
Mailing Address - Fax:218-263-3553
Practice Address - Street 1:306 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2524
Practice Address - Country:US
Practice Address - Phone:218-749-6333
Practice Address - Fax:218-749-2731
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113186-8183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist