Healthcare Provider Details

I. General information

NPI: 1205343415
Provider Name (Legal Business Name): MARTA WALTERS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA FRAGOSO & 65 INFANTERIA PLAZA CAROLINA
CAROLINA PR
00983
US

IV. Provider business mailing address

200 WILMOT RD # 2002
DEERFIELD IL
60015-4620
US

V. Phone/Fax

Practice location:
  • Phone: 787-705-6622
  • Fax:
Mailing address:
  • Phone: 787-769-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number006247
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number006247
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: