Provider Demographics
NPI:1689299273
Name:WALTERS, WADE (RPH)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:WALTERS
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 1:1907 CHESTNUT HILL LN
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4815
Mailing Address - Country:US
Mailing Address - Phone:585-259-8492
Mailing Address - Fax:
Practice Address - Street 1:1411 MIAN STREET
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202
Practice Address - Country:US
Practice Address - Phone:214-749-4092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044720183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist