Provider Demographics
NPI:1174674667
Name:WADDY, ROBERT STEVEN (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEVEN
Last Name:WADDY
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 1:106 SW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067-5129
Mailing Address - Country:US
Mailing Address - Phone:940-325-0734
Mailing Address - Fax:940-328-1991
Practice Address - Street 1:106 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-5129
Practice Address - Country:US
Practice Address - Phone:940-325-0734
Practice Address - Fax:940-328-1991
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144374Medicaid
TX25375OtherPHARMACY LISC. NUMBER
TX25375OtherPHARMACY LISC. NUMBER
PH0739Medicare PIN