Provider Demographics
NPI:1790394765
Name:SIDWELL, WALTER VON BROCK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:VON BROCK
Last Name:SIDWELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4054
Mailing Address - Country:US
Mailing Address - Phone:615-618-9887
Mailing Address - Fax:
Practice Address - Street 1:27955 US HIGHWAY 98 STE 1
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4700
Practice Address - Country:US
Practice Address - Phone:251-626-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI40131183500000X
ALS12081183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist