Healthcare Provider Details

I. General information

NPI: 1508908856
Provider Name (Legal Business Name): WALT E PARENT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S IMPERIAL AVE
EL CENTRO CA
92243
US

IV. Provider business mailing address

1600 S IMPERIAL AVE DESERT MEDICAL PHARMACY
EL CENTRO CA
92243-4242
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-5130
  • Fax: 760-353-4556
Mailing address:
  • Phone: 760-353-5130
  • Fax: 760-353-4556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: