Provider Demographics
NPI:1649573841
Name:WALLS, STACY ANN (RPH)
Entity Type:Individual
Prefix:MISS
First Name:STACY
Middle Name:ANN
Last Name:WALLS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ROUNDHILL RD APT 1403
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1560
Mailing Address - Country:US
Mailing Address - Phone:304-610-5384
Mailing Address - Fax:
Practice Address - Street 1:5 RIVER WALK MALL
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1026
Practice Address - Country:US
Practice Address - Phone:304-744-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist