Provider Demographics
NPI:1528419538
Name:WILLS, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WILLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 N 83RD AVE APT 3091
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5619
Mailing Address - Country:US
Mailing Address - Phone:651-245-0850
Mailing Address - Fax:602-249-3022
Practice Address - Street 1:1825 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2512
Practice Address - Country:US
Practice Address - Phone:602-249-1285
Practice Address - Fax:602-249-3022
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS021887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist