Provider Demographics
NPI:1376829275
Name:WALTHER, JOHN JAMES (BS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JAMES
Last Name:WALTHER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1517
Mailing Address - Country:US
Mailing Address - Phone:262-652-2396
Mailing Address - Fax:262-652-2806
Practice Address - Street 1:7525 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1517
Practice Address - Country:US
Practice Address - Phone:262-652-2396
Practice Address - Fax:262-652-2806
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI119140-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist