Healthcare Provider Details

I. General information

NPI: 1023156395
Provider Name (Legal Business Name): WALTZ & BRAZZEL PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH TRENTON STREET
RUSTON LA
71270
US

IV. Provider business mailing address

200 NORTH TRENTON STREET
RUSTON LA
71270
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-0458
  • Fax: 318-251-3373
Mailing address:
  • Phone: 318-255-0458
  • Fax: 318-251-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3935 1R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. PHIL H WALTZ JR.
Title or Position: OWNER REGISTERED PHARMACIST
Credential: RPH
Phone: 318-255-0458