Provider Demographics
NPI:1104161561
Name:WALLER, JAMIE GLENN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:GLENN
Last Name:WALLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 ELF TRAIL
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055
Mailing Address - Country:US
Mailing Address - Phone:804-921-6303
Mailing Address - Fax:
Practice Address - Street 1:12130 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6908
Practice Address - Country:US
Practice Address - Phone:757-881-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist