Provider Demographics
NPI:1033985635
Name:WALTERS-PEACE, REBECCA LEE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:WALTERS-PEACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 COUNTY ROAD 139
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:MO
Mailing Address - Zip Code:65606-8221
Mailing Address - Country:US
Mailing Address - Phone:417-778-7000
Mailing Address - Fax:
Practice Address - Street 1:201 STATE HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:MO
Practice Address - Zip Code:65606-6380
Practice Address - Country:US
Practice Address - Phone:417-778-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist