Provider Demographics
NPI:1003116005
Name:WALLER, AMY (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WALLER
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 1:7544 GIRARD AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5101
Mailing Address - Country:US
Mailing Address - Phone:858-454-0932
Mailing Address - Fax:858-454-8518
Practice Address - Street 1:7544 GIRARD AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5101
Practice Address - Country:US
Practice Address - Phone:858-454-0932
Practice Address - Fax:858-454-8518
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist