Provider Demographics
NPI:1205423738
Name:DOUGLASS, WALTER JOSEPH
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:JOSEPH
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-1614
Mailing Address - Country:US
Mailing Address - Phone:860-349-3478
Mailing Address - Fax:860-349-1240
Practice Address - Street 1:221 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422-1614
Practice Address - Country:US
Practice Address - Phone:860-349-3478
Practice Address - Fax:860-349-1240
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist