Provider Demographics
NPI:1700066941
Name:COOLBAUGH, WALTER WESLEY (RPH)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:WESLEY
Last Name:COOLBAUGH
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 1:2816 ROSS DR
Mailing Address - Street 2:
Mailing Address - City:WEEDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13166-9764
Mailing Address - Country:US
Mailing Address - Phone:315-834-6038
Mailing Address - Fax:
Practice Address - Street 1:2949 STATE ROUTE 370
Practice Address - Street 2:
Practice Address - City:CATO
Practice Address - State:NY
Practice Address - Zip Code:13033
Practice Address - Country:US
Practice Address - Phone:315-626-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34463183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist