Provider Demographics
NPI:1104019041
Name:WALKER, MARYBETH
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:WALKER
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:PO BOX 1000
Mailing Address - Street 2:MS3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-885-3121
Practice Address - Street 1:2636 ROUTE 32
Practice Address - Street 2:
Practice Address - City:NEW WINSOR
Practice Address - State:NY
Practice Address - Zip Code:12553
Practice Address - Country:US
Practice Address - Phone:845-562-5292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist