Provider Demographics
NPI:1760947253
Name:FORTUNE, WALDRON STEPHENSON
Entity Type:Individual
Prefix:
First Name:WALDRON
Middle Name:STEPHENSON
Last Name:FORTUNE
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 1:2922 S BRONSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-2836
Mailing Address - Country:US
Mailing Address - Phone:323-717-8499
Mailing Address - Fax:
Practice Address - Street 1:2006 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-5913
Practice Address - Country:US
Practice Address - Phone:661-945-2729
Practice Address - Fax:661-949-7022
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC47887183500000X
CAC477847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty