Provider Demographics
NPI:1083942759
Name:WALTZ, PHIL H JR (RPH)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:H
Last Name:WALTZ
Suffix:JR
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 1:2102 KNOWLES DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2619
Mailing Address - Country:US
Mailing Address - Phone:318-255-0659
Mailing Address - Fax:
Practice Address - Street 1:200 N TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-4324
Practice Address - Country:US
Practice Address - Phone:318-255-0458
Practice Address - Fax:318-251-3373
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist