Provider Demographics
NPI:1881886968
Name:WALLEN, MARTHA (PHARMD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:WALLEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9990 NOB HILL CT
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-4630
Mailing Address - Country:US
Mailing Address - Phone:954-572-6598
Mailing Address - Fax:
Practice Address - Street 1:5601 NW 183RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2305
Practice Address - Country:US
Practice Address - Phone:305-760-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist