Provider Demographics
NPI:1710242920
Name:WALTZ, MARK ALAN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:WALTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 LASALLE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-5309
Mailing Address - Country:US
Mailing Address - Phone:734-241-4939
Mailing Address - Fax:
Practice Address - Street 1:1012 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1702
Practice Address - Country:US
Practice Address - Phone:419-478-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03130070183500000X
MI5302410772183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist