Provider Demographics
NPI:1609080191
Name:LEATHERMAN, WALTER JAMES (RPH)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:JAMES
Last Name:LEATHERMAN
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 1:43005 E LARCH MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CORBETT
Mailing Address - State:OR
Mailing Address - Zip Code:97019-8776
Mailing Address - Country:US
Mailing Address - Phone:503-695-5103
Mailing Address - Fax:
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-7526
Practice Address - Fax:541-296-7616
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6732183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist