MEDICARE: WALTER'S PHARMACY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1104159607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALTER'S PHARMACY INC.

Provider Business Mailing Address
First Line	:	2700 INTERNATIONAL BLVD
Second Line	:	SUITE 32
City	:	OAKLAND
State	:	CA
Zip	:	94601-1520
Country	:	US
Telephone Number	:	510-533-2700
Fax Number	:	415-242-1492

Provider Business Practice Location Address
First Line	:	2700 INTERNATIONAL BLVD
Second Line	:	SUITE 32
City	:	OAKLAND
State	:	CA
Zip	:	94601-1520
Country	:	US
Telephone Number	:	510-533-2700
Fax Number	:	415-242-1492

Authorized Official
Title or Position	:	CEO
Name	:	DR. WALTER HARCOURT MULLEN
Credential	:	PHARMD
Telephone Number	:	510-533-2700

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	09/15/2009

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