Healthcare Provider Details

I. General information

NPI: 1083895122
Provider Name (Legal Business Name): EXA WILLIS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD DEPT 119
SALEM VA
24153-6404
US

IV. Provider business mailing address

1970 ROANOKE BLVD DEPT 119
SALEM VA
24153-6404
US

V. Phone/Fax

Practice location:
  • Phone: 540-928-8463
  • Fax: 540-855-3478
Mailing address:
  • Phone: 540-928-8463
  • Fax: 540-855-3478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number15648
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: