=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770792871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES RAY WALL RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 MEMORIAL DR
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35022-6029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-481-2040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6441 MONT RICHER AVE
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37918-9325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-689-9778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 11981
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------