Provider Demographics
NPI:1770650426
Name:L.D. WALTER GROUP
Entity Type:Organization
Organization Name:L.D. WALTER GROUP
Other - Org Name:E.J. WALTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LARONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-330-8011
Mailing Address - Street 1:5415 KELLEY ST
Mailing Address - Street 2:STE D
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77026-1886
Mailing Address - Country:US
Mailing Address - Phone:713-330-8011
Mailing Address - Fax:713-330-3011
Practice Address - Street 1:5415 KELLEY ST
Practice Address - Street 2:STE D
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77026-1886
Practice Address - Country:US
Practice Address - Phone:713-330-8011
Practice Address - Fax:713-330-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29715333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149649Medicaid
2155063OtherPK