Provider Demographics
NPI:1104604503
Name:WALTS, MO
Entity type:Individual
Prefix:
First Name:MO
Middle Name:
Last Name:WALTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:
Other - Last Name:WALTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3606 PARTI DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-8828
Mailing Address - Country:US
Mailing Address - Phone:607-745-7752
Mailing Address - Fax:
Practice Address - Street 1:100 RANO BLVD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2776
Practice Address - Country:US
Practice Address - Phone:607-763-8712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20-102791183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician