Provider Demographics
NPI:1477823771
Name:WALLIN, WARREN LEONARD (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:LEONARD
Last Name:WALLIN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6238 NORTH 155 TH STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-4447
Mailing Address - Country:US
Mailing Address - Phone:402-571-8486
Mailing Address - Fax:
Practice Address - Street 1:5225 NORTH 90 ST STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134
Practice Address - Country:US
Practice Address - Phone:402-408-0304
Practice Address - Fax:402-408-0308
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist