Provider Demographics
NPI:1295125151
Name:WALL, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:WALL
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 1:1308 DUGWAY CT
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5535
Mailing Address - Country:US
Mailing Address - Phone:919-608-6798
Mailing Address - Fax:
Practice Address - Street 1:1308 DUGWAY CT
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5535
Practice Address - Country:US
Practice Address - Phone:919-608-6798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41462183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician