Provider Demographics
NPI:1942582648
Name:WALTERS, MICHAEL JOE (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOE
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 1:1323 N BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1913
Mailing Address - Country:US
Mailing Address - Phone:765-664-2434
Mailing Address - Fax:765-664-3721
Practice Address - Street 1:1323 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1913
Practice Address - Country:US
Practice Address - Phone:765-664-2434
Practice Address - Fax:765-664-3721
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist