Provider Demographics
NPI:1366576076
Name:FALLIS, ERICA LEIGH (RPH)
Entity type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:LEIGH
Last Name:FALLIS
Suffix:
Gender:F
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:PO BOX 7804
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-0977
Mailing Address - Country:US
Mailing Address - Phone:253-863-1004
Mailing Address - Fax:253-588-3658
Practice Address - Street 1:1901 S UNION AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1702
Practice Address - Country:US
Practice Address - Phone:253-453-6200
Practice Address - Fax:253-588-3658
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00014391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist