Provider Demographics
NPI:1518141753
Name:WALL, VANCE TIMOTHY SR (RPH)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:TIMOTHY
Last Name:WALL
Suffix:SR
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:PO BOX 1860
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29834-1860
Mailing Address - Country:US
Mailing Address - Phone:803-593-3411
Mailing Address - Fax:866-838-0951
Practice Address - Street 1:2820 AUGUSTA ROAD
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:SC
Practice Address - Zip Code:29834
Practice Address - Country:US
Practice Address - Phone:803-593-3411
Practice Address - Fax:803-593-6090
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4236OtherSTATE PHARMACY LICENSE
GA13303OtherSTATE PHARMACY LICENSE