Provider Demographics
NPI:1770814881
Name:WALTERS, ANTHONY VICTOR (RPH)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:VICTOR
Last Name:WALTERS
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 1:121 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4043
Mailing Address - Country:US
Mailing Address - Phone:718-381-3621
Mailing Address - Fax:
Practice Address - Street 1:121 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4043
Practice Address - Country:US
Practice Address - Phone:718-381-3621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032112-11835P0018X
NY0321121835P0018X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy