Provider Demographics
NPI:1083895122
Name:WILLIS, EXA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EXA
Middle Name:
Last Name:WILLIS
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 1:1970 ROANOKE BLVD
Mailing Address - Street 2:DEPT 119
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6404
Mailing Address - Country:US
Mailing Address - Phone:540-928-8463
Mailing Address - Fax:540-855-3478
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:DEPT 119
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-928-8463
Practice Address - Fax:540-855-3478
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL156481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist