=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528425832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORY WAKSMUNSKI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2016
-----------------------------------------------------
Last Update Date | 01/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 E STAN SCHLUETER LOOP
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-669-6133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 E STAN SCHLUETER LOOP
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202212335
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 57675
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP448553
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------