Provider Demographics
NPI:1114299856
Name:CANSDALE, WALTER CHARLES JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:CHARLES
Last Name:CANSDALE
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 1:100 LASPINA LN
Mailing Address - Street 2:
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-4804
Mailing Address - Country:US
Mailing Address - Phone:724-863-3104
Mailing Address - Fax:
Practice Address - Street 1:3621 WILLIAM PENN HWY
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-2123
Practice Address - Country:US
Practice Address - Phone:412-372-4097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040424R1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007752900020Medicaid