Provider Demographics
NPI:1720334329
Name:WALLIS, KRYSTAL A (PHARM D)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:A
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:A
Other - Last Name:MELLEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:6265 BROCKPORT SPENCERPORT RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2605
Mailing Address - Country:US
Mailing Address - Phone:585-637-2341
Mailing Address - Fax:585-637-9914
Practice Address - Street 1:6265 BROCKPORT SPENCERPORT RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2605
Practice Address - Country:US
Practice Address - Phone:585-637-2341
Practice Address - Fax:585-637-9914
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist