Provider Demographics
NPI:1306061692
Name:WALL, GERALD E (RP)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:E
Last Name:WALL
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 HARTMANN AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-2211
Mailing Address - Country:US
Mailing Address - Phone:973-478-5833
Mailing Address - Fax:
Practice Address - Street 1:895 PAULISON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3640
Practice Address - Country:US
Practice Address - Phone:973-546-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01391600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist