Healthcare Provider Details

I. General information

NPI: 1659809374
Provider Name (Legal Business Name): BRETTON CLARK WALBERG RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 DONATION RD
GREENVILLE PA
16125-8008
US

IV. Provider business mailing address

260 DONATION RD
GREENVILLE PA
16125-8008
US

V. Phone/Fax

Practice location:
  • Phone: 724-612-2131
  • Fax: 724-588-2047
Mailing address:
  • Phone: 724-612-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP044321L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: