Provider Demographics
NPI:1720224843
Name:WALES, JOSEPHINE D (BS)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:D
Last Name:WALES
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 KINGDOM PLZ
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-8437
Mailing Address - Country:US
Mailing Address - Phone:315-539-5056
Mailing Address - Fax:315-539-9347
Practice Address - Street 1:1963 KINGDOM PLZ
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-8437
Practice Address - Country:US
Practice Address - Phone:315-539-5056
Practice Address - Fax:315-539-9347
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist