Provider Demographics
NPI:1568063949
Name:WALKER, QUATATA LATELL
Entity Type:Individual
Prefix:
First Name:QUATATA
Middle Name:LATELL
Last Name:WALKER
Suffix:
Gender:F
Credentials:
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 338
Mailing Address - Street 2:
Mailing Address - City:MARSHALLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31057-0338
Mailing Address - Country:US
Mailing Address - Phone:478-997-0171
Mailing Address - Fax:
Practice Address - Street 1:502 BOOTH RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3422
Practice Address - Country:US
Practice Address - Phone:478-918-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty