Provider Demographics
NPI:1740881630
Name:WADDELL, TED ALAN (PHARMD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:ALAN
Last Name:WADDELL
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 1:15 TEXAS STATION CT
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-8263
Mailing Address - Country:US
Mailing Address - Phone:410-628-7264
Mailing Address - Fax:
Practice Address - Street 1:15 TEXAS STATION CT
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-8263
Practice Address - Country:US
Practice Address - Phone:410-628-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist