MEDICARE: WALTER MONROE MASSEY III RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH014485	GA

General Provider Information

NPI Number	:	1225637499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER MONROE MASSEY III RPH

Provider Business Mailing Address
First Line	:	2463 WOOD TRAIL LN
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-4846
Country	:	US
Telephone Number	:	404-314-9077
Fax Number	:

Provider Business Practice Location Address
First Line	:	1227 ROCKBRIDGE RD
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-3064
Country	:	US
Telephone Number	:	770-225-1888
Fax Number	:	770-225-1889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2020
Last Update Date	:	10/20/2020

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