Healthcare Provider Details

I. General information

NPI: 1962727131
Provider Name (Legal Business Name): WALTER GUSTAV HAGUES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 BLACK RIVER BOULEVARD
ROME NY
13440-0000
US

IV. Provider business mailing address

1727 BLACK RIVER BOULEVARD
ROME NY
13440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 315-336-8890
  • Fax: 315-339-6499
Mailing address:
  • Phone: 315-336-8890
  • Fax: 315-339-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24349
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: