Provider Demographics
NPI:1720364508
Name:WALLAR, JAMI
Entity Type:Individual
Prefix:
First Name:JAMI
Middle Name:
Last Name:WALLAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9823 ROSEMILL CIR
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-2655
Mailing Address - Country:US
Mailing Address - Phone:763-427-0064
Mailing Address - Fax:
Practice Address - Street 1:10686 UNIVERSITY AVE NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-6141
Practice Address - Country:US
Practice Address - Phone:763-755-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist