Provider Demographics
NPI:1912218835
Name:WALL, TROY THERLE (RPH)
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:THERLE
Last Name:WALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5478 HIGHWAY 153
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3782
Mailing Address - Country:US
Mailing Address - Phone:423-875-0855
Mailing Address - Fax:423-875-3164
Practice Address - Street 1:5478 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3782
Practice Address - Country:US
Practice Address - Phone:423-875-0855
Practice Address - Fax:423-875-3164
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23577183500000X
TX29804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist