Provider Demographics
NPI:1407914146
Name:CHEATUM, WAYNE CLARK (R PH)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:CLARK
Last Name:CHEATUM
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13027 WILD HEART
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-3968
Mailing Address - Country:US
Mailing Address - Phone:210-265-5036
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR SUITE 1
Practice Address - Street 2:59 MDTS PHARMACY
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-7216
Practice Address - Fax:210-292-3722
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist