MEDICARE: RICHARD WALLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302040235	MI

General Provider Information

NPI Number	:	1538790225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD WALLS

Provider Business Mailing Address
First Line	:	18600 LIVERNOIS AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-2257
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18600 LIVERNOIS AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-2257
Country	:	US
Telephone Number	:	313-345-6020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2020
Last Update Date	:	01/31/2020

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Directions to “ RICHARD WALLS ” Practice Location

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