Provider Demographics
NPI:1831625912
Name:WALLIS, MARLENE LIBBY (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:LIBBY
Last Name:WALLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7081 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5108
Mailing Address - Country:US
Mailing Address - Phone:760-617-3190
Mailing Address - Fax:
Practice Address - Street 1:7081 SVL BOX
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5108
Practice Address - Country:US
Practice Address - Phone:760-617-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist