Provider Demographics
NPI:1467510891
Name:WALLIS ENTERPRISES INC
Entity Type:Organization
Organization Name:WALLIS ENTERPRISES INC
Other - Org Name:LAS CRUCES REXALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:505-524-2863
Mailing Address - Street 1:2140 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1129
Mailing Address - Country:US
Mailing Address - Phone:505-524-2863
Mailing Address - Fax:505-525-3192
Practice Address - Street 1:2140 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1129
Practice Address - Country:US
Practice Address - Phone:505-524-2863
Practice Address - Fax:505-525-3192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000015463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1312980001Medicare ID - Type Unspecified