Provider Demographics
NPI:1659984094
Name:WALL, LARAMIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LARAMIE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6330
Mailing Address - Country:US
Mailing Address - Phone:479-756-1355
Mailing Address - Fax:479-756-1501
Practice Address - Street 1:2002 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6330
Practice Address - Country:US
Practice Address - Phone:479-756-1355
Practice Address - Fax:479-756-1501
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist