Provider Demographics
NPI:1265587406
Name:WALTERS, DAN R (RPH)
Entity type:Individual
Prefix:MR
First Name:DAN
Middle Name:R
Last Name:WALTERS
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 1:1202 WESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2335
Mailing Address - Country:US
Mailing Address - Phone:920-686-0877
Mailing Address - Fax:
Practice Address - Street 1:2219 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-2416
Practice Address - Country:US
Practice Address - Phone:920-793-2927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI11368183500000X
OH03-3-16891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist