Provider Demographics
NPI:1851459465
Name:WALTZ PHARMACY, INC
Entity Type:Organization
Organization Name:WALTZ PHARMACY, INC
Other - Org Name:PITTSFIELD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-230-1053
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04843-0130
Mailing Address - Country:US
Mailing Address - Phone:207-230-1053
Mailing Address - Fax:207-230-0039
Practice Address - Street 1:166 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:ME
Practice Address - Zip Code:04967
Practice Address - Country:US
Practice Address - Phone:207-487-5424
Practice Address - Fax:207-487-5626
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALTZ PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME332B00000X
MEPH500012243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003012OtherANTHEM HME PROVIDER #
ME2006915OtherNABP#
ME0128450005Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID#