1568499234 NPI number — MR. JEFFREY A. WALLACE I R.PH.

Table of content: MR. JEFFREY A. WALLACE I R.PH. (NPI 1568499234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568499234 NPI number — MR. JEFFREY A. WALLACE I R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
JEFFREY
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
R.PH.
Provider Gender Code:
M

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:
1568499234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5420 LANCASTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44131-1832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5420 LANCASTER DR
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE PHARMACY ADMINISTRATION
Provider Business Practice Location Address City Name:
BROOKLYN HEIGHTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44131-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-749-8408
Provider Business Practice Location Address Fax Number:
216-749-8426
Provider Enumeration Date:
06/27/2006

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:  03-3-10464 , 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)





Copyright © 2007-2025 www.npivalidator.com