Healthcare Provider Details

I. General information

NPI: 1679095475
Provider Name (Legal Business Name): TY MACWALTERS CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER ROAD CENTRAL VERMONT MEDICAL CENTER
BERLIN VT
05602-0560
US

IV. Provider business mailing address

PO BOX 547
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-371-4857
  • Fax: 802-371-4408
Mailing address:
  • Phone: 802-371-4169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number037.0001187
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: