Healthcare Provider Details

I. General information

NPI: 1669391033
Provider Name (Legal Business Name): JACOB KEITH WALTERS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

PO BOX 2712
ROANOKE VA
24001-2712
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax:
Mailing address:
  • Phone: 336-858-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202223717
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: