Provider Demographics
NPI:1770627390
Name:WALDEN, WILLIAM ALLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ALLEN
Last Name:WALDEN
Suffix:
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 1:793 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4576
Mailing Address - Country:US
Mailing Address - Phone:706-632-2244
Mailing Address - Fax:706-632-4440
Practice Address - Street 1:793 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4576
Practice Address - Country:US
Practice Address - Phone:706-632-2244
Practice Address - Fax:706-632-4440
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1106788Medicaid
GA22107AMedicaid
GA1106788Medicaid