Provider Demographics
NPI:1376289116
Name:WALETICH, MARVIN JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:JAMES
Last Name:WALETICH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:WALETICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-0188
Mailing Address - Country:US
Mailing Address - Phone:360-274-8211
Mailing Address - Fax:360-274-7825
Practice Address - Street 1:117 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611
Practice Address - Country:US
Practice Address - Phone:360-274-8211
Practice Address - Fax:360-274-7825
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHRM.PH.00009701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist