1548590441 NPI number — MRS. SUZI ANN WALLACE BS PHARMACY

Table of content: MRS. SUZI ANN WALLACE BS PHARMACY (NPI 1548590441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548590441 NPI number — MRS. SUZI ANN WALLACE BS PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
SUZI
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BS PHARMACY
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:
1548590441
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 DEACONESS RD
Provider Second Line Business Mailing Address:
WEST CAMPUS IND PHARMACY CCB-011
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-5321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-754-3844
Provider Business Mailing Address Fax Number:
617-754-3845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 DEACONESS RD
Provider Second Line Business Practice Location Address:
WEST CAMPUS IND PHARMACY CCB-011
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215-5321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-754-3844
Provider Business Practice Location Address Fax Number:
617-754-3845
Provider Enumeration Date:
12/28/2009

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:  PH23379 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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