Provider Demographics
NPI:1245507490
Name:WALLER, JASON LEE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:LEE
Last Name:WALLER
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 1:1013 TRAFFORD LN
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-5115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11509 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1901
Practice Address - Country:US
Practice Address - Phone:912-927-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist