Provider Demographics
NPI:1114361938
Name:WALLER, CHRISTOPHER DREW
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DREW
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18586 ROUTE 52
Mailing Address - Street 2:
Mailing Address - City:FORT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25514-7046
Mailing Address - Country:US
Mailing Address - Phone:304-617-2242
Mailing Address - Fax:
Practice Address - Street 1:18586 ROUTE 52
Practice Address - Street 2:
Practice Address - City:FORT GAY
Practice Address - State:WV
Practice Address - Zip Code:25514-7046
Practice Address - Country:US
Practice Address - Phone:304-617-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017245183500000X
OH03234139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist