Healthcare Provider Details

I. General information

NPI: 1467510891
Provider Name (Legal Business Name): WALLIS ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 N MAIN ST
LAS CRUCES NM
88001-1129
US

IV. Provider business mailing address

2140 N MAIN ST
LAS CRUCES NM
88001-1129
US

V. Phone/Fax

Practice location:
  • Phone: 505-524-2863
  • Fax: 505-525-3192
Mailing address:
  • Phone: 505-524-2863
  • Fax: 505-525-3192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00001546
License Number StateNM

VIII. Authorized Official

Name: SCOTT W WALLIS
Title or Position: PRESIDENT
Credential: R. PH.
Phone: 505-524-2863