Healthcare Provider Details

I. General information

NPI: 1528121142
Provider Name (Legal Business Name): WALTZ PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 ELM ST
CAMDEN ME
04843-1942
US

IV. Provider business mailing address

PO BOX 130
CAMDEN ME
04843-0130
US

V. Phone/Fax

Practice location:
  • Phone: 207-236-2240
  • Fax: 207-236-9489
Mailing address:
  • Phone: 207-236-2240
  • Fax: 207-236-9489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier003012
Identifier TypeOTHER
Identifier StateME
Identifier IssuerANTHEM BLUE CROSS ID#
# 2
Identifier101460005
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer
# 3
Identifier048613
Identifier TypeOTHER
Identifier StateME
Identifier IssuerBLUE CROSS

VIII. Authorized Official

Name: DEAN JACOBS
Title or Position: PRESIDENT
Credential: RPH
Phone: 866-415-1954