Provider Demographics
NPI:1821694159
Name:WALLIS, ANNA LENORE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:LENORE
Last Name:WALLIS
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 1:390 NE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-2508
Mailing Address - Country:US
Mailing Address - Phone:405-290-3000
Mailing Address - Fax:
Practice Address - Street 1:2400 CORNWELL DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-5804
Practice Address - Country:US
Practice Address - Phone:405-354-7449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist