MEDICARE: MISS MELISSA CARRIE WALTERS PHARMD

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	183500000X	Pharmacist	PS40617	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS40617	OTHER	FL	STATE PHARMACIST LICENSE NUMBER

General Provider Information

NPI Number	:	1386917920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MELISSA CARRIE WALTERS PHARMD

Provider Business Mailing Address
First Line	:	1802 JIM REDMAN PKWY
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-6914
Country	:	US
Telephone Number	:	813-752-6192
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 JIM REDMAN PKWY
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-6914
Country	:	US
Telephone Number	:	813-752-6192
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	02/13/2012

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