Provider Demographics
NPI:1891844395
Name:WILLIS, ANDREW RYAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:RYAN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 LAKE MURRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2502
Mailing Address - Country:US
Mailing Address - Phone:619-465-5195
Mailing Address - Fax:619-465-5242
Practice Address - Street 1:6136 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2502
Practice Address - Country:US
Practice Address - Phone:619-465-5195
Practice Address - Fax:619-465-5242
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist