Provider Demographics
NPI:1821621624
Name:WALLSTEN, ALANNAH L (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALANNAH
Middle Name:L
Last Name:WALLSTEN
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 1:999 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2210
Mailing Address - Country:US
Mailing Address - Phone:920-324-4696
Mailing Address - Fax:
Practice Address - Street 1:999 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2210
Practice Address - Country:US
Practice Address - Phone:920-324-4696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20036-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist