Provider Demographics
NPI:1952063760
Name:WALL, WILLIAM JAMES JR
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JAMES
Last Name:WALL
Suffix:JR
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 1:1820 HUNTINGTON PARK DR APT 1112
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1467
Mailing Address - Country:US
Mailing Address - Phone:757-968-2731
Mailing Address - Fax:
Practice Address - Street 1:150 VIKING DR
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1435
Practice Address - Country:US
Practice Address - Phone:608-524-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21157-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist