1093098063 NPI number — MS. KRISTIE L MEACHEAM WALLACE RPH

Table of content: MS. KRISTIE L MEACHEAM WALLACE RPH (NPI 1093098063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093098063 NPI number — MS. KRISTIE L MEACHEAM WALLACE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEACHEAM WALLACE
Provider First Name:
KRISTIE
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093098063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1039 E MARYLAND CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65810-2982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-890-7093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 W MARLER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OZARK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65721-7661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-581-3288
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  044157 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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