Provider Demographics
NPI:1336689801
Name:WALLER, RONALD EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:EDWARD
Last Name:WALLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 HIGHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6019
Mailing Address - Country:US
Mailing Address - Phone:601-956-1132
Mailing Address - Fax:800-874-9908
Practice Address - Street 1:240 HIGHPOINT DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6019
Practice Address - Country:US
Practice Address - Phone:601-956-1132
Practice Address - Fax:800-874-9908
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-07979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist