=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003908633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER JOSEPH CZAJKA RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 EAST MARKET STR NORTHERN DUTCHESS PHARMACY INC
-----------------------------------------------------
City | RHINEBECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-876-3939
-----------------------------------------------------
Fax | 845-876-0466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 ELM STR
-----------------------------------------------------
City | RED HOOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-758-3223
-----------------------------------------------------
Fax | 845-876-0466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 034465
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------