Provider Demographics
NPI:1396567046
Name:WALLEN, GRANT (PHARMD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:WALLEN
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 1:1270 MEADOWLANDS CR
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37876
Mailing Address - Country:US
Mailing Address - Phone:865-253-2769
Mailing Address - Fax:
Practice Address - Street 1:524 ANDREW JOHNSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:STRAWBERRY PLAINS
Practice Address - State:TN
Practice Address - Zip Code:37871
Practice Address - Country:US
Practice Address - Phone:865-933-4149
Practice Address - Fax:865-933-4037
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist