Provider Demographics
NPI:1700126786
Name:WALLS, MARK ANTHONY (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:WALLS
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TIMBER NOOK
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-8151
Mailing Address - Country:US
Mailing Address - Phone:828-236-1519
Mailing Address - Fax:828-236-1522
Practice Address - Street 1:1124 PATTON AVE
Practice Address - Street 2:KERR DRUG
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806
Practice Address - Country:US
Practice Address - Phone:828-236-1519
Practice Address - Fax:828-236-1522
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0116730Medicaid
NC0116730Medicaid