Provider Demographics
NPI:1932819190
Name:WALTER, TIFFANY COLETTE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:COLETTE
Last Name:WALTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 N SUSQUEHANNA TRL
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-7766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:980 N SUSQUEHANNA TRL
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-7766
Practice Address - Country:US
Practice Address - Phone:570-374-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP457357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist