Provider Demographics
NPI:1619001922
Name:WALTER, MARK STEVEN (PD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:WALTER
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:SC
Mailing Address - Zip Code:29477-7507
Mailing Address - Country:US
Mailing Address - Phone:843-563-3426
Mailing Address - Fax:
Practice Address - Street 1:7107 CHARLESTON HIGHWAY
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:SC
Practice Address - Zip Code:29018
Practice Address - Country:US
Practice Address - Phone:803-829-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist