Provider Demographics
NPI:1700174539
Name:WALCK, JASON LAWRENCE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LAWRENCE
Last Name:WALCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 EAST PERSHING BLVD
Mailing Address - Street 2:PHARMACY 119
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001
Mailing Address - Country:US
Mailing Address - Phone:307-778-7550
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD # 119
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054562183500000X
WY91039111835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No183500000XPharmacy Service ProvidersPharmacist