Provider Demographics
NPI:1154480390
Name:WALL, CYNTHIA SHIRLEY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:SHIRLEY
Last Name:WALL
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 1:34414 245TH ST
Mailing Address - Street 2:
Mailing Address - City:CHAMBERLAIN
Mailing Address - State:SD
Mailing Address - Zip Code:57325
Mailing Address - Country:US
Mailing Address - Phone:605-734-6957
Mailing Address - Fax:
Practice Address - Street 1:HWY 47 AND 34
Practice Address - Street 2:
Practice Address - City:FT. THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339
Practice Address - Country:US
Practice Address - Phone:605-245-1503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist