Provider Demographics
NPI:1710663307
Name:WADDELL, CHARLES PARKER (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PARKER
Last Name:WADDELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 E BERNICE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8060
Mailing Address - Country:US
Mailing Address - Phone:208-890-6613
Mailing Address - Fax:
Practice Address - Street 1:3499 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5848
Practice Address - Country:US
Practice Address - Phone:208-605-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDI54205390200000X
IDP10754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program