Provider Demographics
NPI:1265584791
Name:WALLS, ALLEN P (PHIL) (RPH)
Entity type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:P (PHIL)
Last Name:WALLS
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 1:17937 BAHAMA ISLE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2777
Mailing Address - Country:US
Mailing Address - Phone:813-982-9780
Mailing Address - Fax:
Practice Address - Street 1:5706 BENJAMIN CENTER DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5262
Practice Address - Country:US
Practice Address - Phone:813-514-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20125183500000X
GA12646183500000X
ARPD08997183500000X
MI5302033233183500000X
LA17435183500000X
NE12123183500000X
TN11362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist