Healthcare Provider Details

I. General information

NPI: 1376289116
Provider Name (Legal Business Name): MARVIN JAMES WALETICH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JIM WALETICH RPH

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 05/05/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 1ST AVE SW
CASTLE ROCK WA
98611
US

IV. Provider business mailing address

PO BOX 188
CASTLE ROCK WA
98611-0188
US

V. Phone/Fax

Practice location:
  • Phone: 360-274-8211
  • Fax: 360-274-7825
Mailing address:
  • Phone: 360-274-8211
  • Fax: 360-274-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHRM.PH.00009701
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: