Provider Demographics
NPI:1205127602
Name:WADDELL, THOMAS WALTER (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WALTER
Last Name:WADDELL
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 1:9 MERRY OAK TRL
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-9784
Mailing Address - Country:US
Mailing Address - Phone:864-306-6213
Mailing Address - Fax:
Practice Address - Street 1:429 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1574
Practice Address - Country:US
Practice Address - Phone:864-843-9326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist