Provider Demographics
NPI:1134718695
Name:WALKER, EDWINA G
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:G
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-0536
Mailing Address - Country:US
Mailing Address - Phone:940-683-4011
Mailing Address - Fax:940-683-4981
Practice Address - Street 1:810 WW RAY CIR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2061
Practice Address - Country:US
Practice Address - Phone:940-683-4011
Practice Address - Fax:940-683-4981
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist