MEDICARE: MR. ALLEN P (PHIL) WALLS R.PH.

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	20125	FL
2	183500000X	Pharmacist	12646	GA
3	183500000X	Pharmacist	PD08997	AR
4	183500000X	Pharmacist	5302033233	MI
5	183500000X	Pharmacist	17435	LA
6	183500000X	Pharmacist	12123	NE
7	183500000X	Pharmacist	11362	TN

General Provider Information

NPI Number	:	1265584791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALLEN P (PHIL) WALLS R.PH.

Provider Business Mailing Address
First Line	:	17937 BAHAMA ISLE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2777
Country	:	US
Telephone Number	:	813-982-9780
Fax Number	:

Provider Business Practice Location Address
First Line	:	5706 BENJAMIN CENTER DR
Second Line	:	SUITE 103
City	:	TAMPA
State	:	FL
Zip	:	33634-5262
Country	:	US
Telephone Number	:	813-514-0494
Fax Number	:

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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