Provider Demographics
NPI:1861832388
Name:WALLILA, CARL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:WALLILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 SE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-3324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-3324
Practice Address - Country:US
Practice Address - Phone:406-628-8746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist