Provider Demographics
NPI:1124533419
Name:COOLEY, WALTER ALLAN
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:ALLAN
Last Name:COOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 NORTHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2180
Mailing Address - Country:US
Mailing Address - Phone:209-526-5023
Mailing Address - Fax:
Practice Address - Street 1:1080 W F ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3677
Practice Address - Country:US
Practice Address - Phone:209-847-2226
Practice Address - Fax:209-847-2226
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist