Healthcare Provider Details

I. General information

NPI: 1619001922
Provider Name (Legal Business Name): MARK STEVEN WALTER PD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7107 CHARLESTON HIGHWAY
BOWMAN SC
29018
US

IV. Provider business mailing address

289 COUNTRY CLUB BLVD
SAINT GEORGE SC
29477-7507
US

V. Phone/Fax

Practice location:
  • Phone: 803-829-2547
  • Fax:
Mailing address:
  • Phone: 843-563-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5530
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: