Healthcare Provider Details

I. General information

NPI: 1053549113
Provider Name (Legal Business Name): WALTER D LAZENKA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 ROSS CIRCLE
POUGHKEEPSIE NY
12601
US

IV. Provider business mailing address

10 ROSS CIRCLE
POUGHKEEPSIE NY
12601
US

V. Phone/Fax

Practice location:
  • Phone: 845-483-3183
  • Fax:
Mailing address:
  • Phone: 845-483-3183
  • Fax: 845-483-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number028158-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: