Provider Demographics
NPI:1235438342
Name:TAYLOR, WALTER THEODORE
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:THEODORE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 JERRY CLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-3077
Mailing Address - Country:US
Mailing Address - Phone:662-746-9926
Mailing Address - Fax:662-746-9160
Practice Address - Street 1:1220 JERRY CLOWER BLVD
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-3077
Practice Address - Country:US
Practice Address - Phone:662-746-9926
Practice Address - Fax:662-746-9160
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-05343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist