Provider Demographics
NPI:1760410567
Name:PRUITT, WALTER HENRY II (RPH)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:HENRY
Last Name:PRUITT
Suffix:II
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 1:5709 OAK VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-7293
Mailing Address - Country:US
Mailing Address - Phone:706-886-0530
Mailing Address - Fax:
Practice Address - Street 1:1197 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6028
Practice Address - Country:US
Practice Address - Phone:706-886-8711
Practice Address - Fax:706-886-4956
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist