Provider Demographics
NPI:1497860423
Name:WALFER CORP
Entity Type:Organization
Organization Name:WALFER CORP
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:941-627-9855
Mailing Address - Street 1:3524B TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3524 TAMIAMI TRL # B
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8100
Practice Address - Country:US
Practice Address - Phone:941-627-9855
Practice Address - Fax:941-627-0658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH9089333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1052719OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL101838800Medicaid
FLBT0129999OtherDEA #