Provider Demographics
NPI:1336514413
Name:WALTERS, TREVOR (PHARM D)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:DALTON
Other - Middle Name:TREVOR
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:201 LAKESHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-7105
Mailing Address - Country:US
Mailing Address - Phone:205-941-0376
Mailing Address - Fax:205-941-0934
Practice Address - Street 1:201 LAKESHORE PKWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-7105
Practice Address - Country:US
Practice Address - Phone:205-941-0376
Practice Address - Fax:205-941-0934
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL15731OtherCONTROLLED SUBSTANCE REGISTRATION NUMBER, ALABAMA STATE BOARD OF PHARMACY