Provider Demographics
NPI:1568065050
Name:WALTER, SHANE C
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:C
Last Name:WALTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WILSON CIR W
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5831
Mailing Address - Country:US
Mailing Address - Phone:419-953-1244
Mailing Address - Fax:
Practice Address - Street 1:130 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1814
Practice Address - Country:US
Practice Address - Phone:732-542-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03884100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist