1730451543 NPI number — ERIN WALLACE PHARM.D

Table of content: ERIN WALLACE PHARM.D (NPI 1730451543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730451543 NPI number — ERIN WALLACE PHARM.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
ERIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D
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:
1730451543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1604
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILLON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80435-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-468-0287
Provider Business Mailing Address Fax Number:
970-468-7879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
269 DILLON RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80435-8801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-468-0287
Provider Business Practice Location Address Fax Number:
937-431-8672
Provider Enumeration Date:
02/09/2012

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:  03125960-1 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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