Provider Demographics
NPI:1295000131
Name:WALTERS, MITZI ZACK (RPH)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:ZACK
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 GOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2315
Mailing Address - Country:US
Mailing Address - Phone:818-985-6215
Mailing Address - Fax:
Practice Address - Street 1:13550 PAXTON ST
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-2352
Practice Address - Country:US
Practice Address - Phone:818-272-2709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40039183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist