Provider Demographics
NPI:1184971806
Name:WALTER, MICAH EVAN (PHARMD, RPH,CIP)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:EVAN
Last Name:WALTER
Suffix:
Gender:M
Credentials:PHARMD, RPH,CIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3222
Mailing Address - Country:US
Mailing Address - Phone:541-451-8020
Mailing Address - Fax:
Practice Address - Street 1:314 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417
Practice Address - Country:US
Practice Address - Phone:541-839-4452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011846183500000X
ORRP-00118461835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist