Provider Demographics
NPI:1407939861
Name:PEARSON, WALTER STEPHEN SR (RPH- PHARMACIST)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:STEPHEN
Last Name:PEARSON
Suffix:SR
Gender:M
Credentials:RPH- PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-0509
Mailing Address - Country:US
Mailing Address - Phone:662-456-2551
Mailing Address - Fax:662-456-3020
Practice Address - Street 1:101 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2225
Practice Address - Country:US
Practice Address - Phone:662-456-2551
Practice Address - Fax:662-456-3020
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00034747Medicaid
MS0286620001Medicare ID - Type Unspecified