Provider Demographics
NPI:1679769467
Name:WALBERG, MARK PAUL (PHARMD, MA)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:PAUL
Last Name:WALBERG
Suffix:
Gender:M
Credentials:PHARMD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10437 HENSHAW DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7153
Mailing Address - Country:US
Mailing Address - Phone:805-338-5546
Mailing Address - Fax:
Practice Address - Street 1:10437 HENSHAW DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7153
Practice Address - Country:US
Practice Address - Phone:805-338-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist