Provider Demographics
NPI:1639842859
Name:WALTERS, REBECCA ANNE (PHARM D)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FOLSOM LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3316
Mailing Address - Country:US
Mailing Address - Phone:631-946-1089
Mailing Address - Fax:
Practice Address - Street 1:750 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2542
Practice Address - Country:US
Practice Address - Phone:631-924-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067936183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist