Provider Demographics
NPI:1962727131
Name:HAGUES, WALTER GUSTAV (RPH)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:GUSTAV
Last Name:HAGUES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 BLACK RIVER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-0000
Mailing Address - Country:US
Mailing Address - Phone:315-336-8890
Mailing Address - Fax:315-339-6499
Practice Address - Street 1:1727 BLACK RIVER BOULEVARD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-0000
Practice Address - Country:US
Practice Address - Phone:315-336-8890
Practice Address - Fax:315-339-6499
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist