Provider Demographics
NPI:1811573801
Name:QUALLS, WENDELL
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:
Last Name:QUALLS
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 1:4776 BOILING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:OHATCHEE
Mailing Address - State:AL
Mailing Address - Zip Code:36271-6319
Mailing Address - Country:US
Mailing Address - Phone:256-613-1989
Mailing Address - Fax:
Practice Address - Street 1:4776 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OHATCHEE
Practice Address - State:AL
Practice Address - Zip Code:36271-6319
Practice Address - Country:US
Practice Address - Phone:256-613-1989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist