Basic Information
| Provider Information | |||||||||
| NPI: | 1407914146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEATUM | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R. PH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13027 WILD HEART | ||||||||
| Address2: | |||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780233968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102655036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 BERGQUIST DR SUITE 1 | ||||||||
| Address2: | 59 MDTS PHARMACY | ||||||||
| City: | LACKLAND AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782369908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102927216 | ||||||||
| FaxNumber: | 2102923722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS19080 | FL | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.