Healthcare Provider Details

I. General information

NPI: 1093704017
Provider Name (Legal Business Name): DONNA SUE WALL PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD UH1451
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

6918 BRETTON CIR
INDIANAPOLIS IN
46268-2766
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7398
  • Fax: 317-278-1044
Mailing address:
  • Phone: 317-298-7099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26014162
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: