Provider Demographics
NPI:1679295026
Name:WALLS, JAMILAH
Entity type:Individual
Prefix:
First Name:JAMILAH
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24765 MABRAY AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1433
Mailing Address - Country:US
Mailing Address - Phone:313-510-7420
Mailing Address - Fax:
Practice Address - Street 1:24765 MABRAY AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1433
Practice Address - Country:US
Practice Address - Phone:313-510-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist