Provider Demographics
NPI:1972638153
Name:WAYILA, NOWELL
Entity Type:Individual
Prefix:MR
First Name:NOWELL
Middle Name:
Last Name:WAYILA
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 1:9431 SAN MIGUEL DR
Mailing Address - Street 2:APT. D
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1250
Mailing Address - Country:US
Mailing Address - Phone:317-292-3052
Mailing Address - Fax:317-845-1281
Practice Address - Street 1:7320 E 82ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1458
Practice Address - Country:US
Practice Address - Phone:317-842-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021628A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist