Provider Demographics
NPI:1295270130
Name:WILLIS, HAROLD
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name:WILLIS
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 1:3004 US HIGHWAY 23 N
Mailing Address - Street 2:
Mailing Address - City:WEBER CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24290-7087
Mailing Address - Country:US
Mailing Address - Phone:276-386-2118
Mailing Address - Fax:276-386-2611
Practice Address - Street 1:3004 US HIGHWAY 23 N
Practice Address - Street 2:
Practice Address - City:WEBER CITY
Practice Address - State:VA
Practice Address - Zip Code:24290-7087
Practice Address - Country:US
Practice Address - Phone:276-386-2118
Practice Address - Fax:276-386-2611
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005147183500000X
TN0000010990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist