Provider Demographics
NPI:1538101548
Name:WALL, MICHAEL J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:WALL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:MAGUIRE BUILDING 3909
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9335
Mailing Address - Fax:708-216-7867
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:MAGUIRE BUILDING 3909
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9335
Practice Address - Fax:708-216-7867
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5302033564183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist