Provider Demographics
NPI:1962024042
Name:WALL, ANDREW CLINTON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CLINTON
Last Name:WALL
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 1:8915 HARRY HINES BLVD STE P
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-1717
Mailing Address - Country:US
Mailing Address - Phone:972-548-9484
Mailing Address - Fax:214-352-0871
Practice Address - Street 1:2801 LEMMON AVE STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2396
Practice Address - Country:US
Practice Address - Phone:469-749-7824
Practice Address - Fax:469-749-7825
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist