Provider Demographics
NPI:1891121885
Name:WALLER, JEFFREY ROBERT
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ROBERT
Last Name:WALLER
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 1:2185 REEVES ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2349
Mailing Address - Country:US
Mailing Address - Phone:334-794-0623
Mailing Address - Fax:334-794-9526
Practice Address - Street 1:2185 REEVES ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2349
Practice Address - Country:US
Practice Address - Phone:334-794-0623
Practice Address - Fax:334-794-9526
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist