Provider Demographics
NPI:1679095475
Name:MACWALTERS, TY (CPHT)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:MACWALTERS
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-371-4169
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER ROAD
Practice Address - Street 2:CENTRAL VERMONT MEDICAL CENTER
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-0560
Practice Address - Country:US
Practice Address - Phone:802-371-4857
Practice Address - Fax:802-371-4408
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT037.00011873336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT121.0000650OtherSTATE LICENSE