Provider Demographics
NPI:1497376222
Name:ROGERS, WALTER (RPH)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 DOLPHIN POINT RD
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3719
Mailing Address - Country:US
Mailing Address - Phone:850-499-1176
Mailing Address - Fax:
Practice Address - Street 1:251 MIRACLE STRIP PKWY SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5853
Practice Address - Country:US
Practice Address - Phone:850-796-1937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51534183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist