MEDICARE: MR. WALTER G TENNYSON 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	183500000X	Pharmacist	9529	GA

General Provider Information

NPI Number	:	1871881532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER G TENNYSON RPH

Provider Business Mailing Address
First Line	:	1799 BRIARCLIFF RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-2142
Country	:	US
Telephone Number	:	404-873-3438
Fax Number	:	404-875-1681

Provider Business Practice Location Address
First Line	:	1799 BRIARCLIFF RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-2142
Country	:	US
Telephone Number	:	404-873-3438
Fax Number	:	404-875-1681

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

Provider Enumeration Date	:	07/15/2011
Last Update Date	:	07/15/2011

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