Provider Demographics
NPI:1093861957
Name:WALLY, BERNARD (R PH)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:WALLY
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PECAN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5545
Mailing Address - Country:US
Mailing Address - Phone:845-638-3832
Mailing Address - Fax:
Practice Address - Street 1:66 MIDDLEBUSH RD
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-4098
Practice Address - Country:US
Practice Address - Phone:845-296-1973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist