Healthcare Provider Details

I. General information

NPI: 1326150244
Provider Name (Legal Business Name): GERALD J WALDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9723 SIERRA VISTA RD STE E
PHELAN CA
92371-8271
US

IV. Provider business mailing address

PO BOX 1970
WRIGHTWOOD CA
92397-1970
US

V. Phone/Fax

Practice location:
  • Phone: 760-868-6526
  • Fax: 760-868-6868
Mailing address:
  • Phone: 760-249-3081
  • Fax: 760-868-6868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY41829
License Number StateCA

VIII. Authorized Official

Name: JERRY WALDE
Title or Position: PHARMACIST OWNER
Credential: PHARMD
Phone: 760-868-6526