Provider Demographics
NPI:1174932636
Name:WALLER, SHONDA SHANELLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SHONDA
Middle Name:SHANELLE
Last Name:WALLER
Suffix:
Gender:F
Credentials:PHARMD
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 8600
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32006-0014
Mailing Address - Country:US
Mailing Address - Phone:302-983-7404
Mailing Address - Fax:
Practice Address - Street 1:1302 RIVER ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5042
Practice Address - Country:US
Practice Address - Phone:386-328-0558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist