Provider Demographics
NPI:1689260762
Name:WALBOM, PAUL DEBARTON (RPH)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DEBARTON
Last Name:WALBOM
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 1:875 RIO VIRGIN DR UNIT 276
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7866
Mailing Address - Country:US
Mailing Address - Phone:435-319-8015
Mailing Address - Fax:
Practice Address - Street 1:700 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6152
Practice Address - Country:US
Practice Address - Phone:208-523-0831
Practice Address - Fax:208-525-4752
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP57031835C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care