1710038716 NPI number — WALLACE PHARMACY INC

Table of content: (NPI 1710038716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710038716 NPI number — WALLACE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1710038716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 S MAIN
Provider Second Line Business Mailing Address:
PO BOX 841
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83210-0841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-397-4540
Provider Business Mailing Address Fax Number:
208-397-5215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 S MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83210-0841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-397-4540
Provider Business Practice Location Address Fax Number:
208-397-5215
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
DWIGHT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PIC
Authorized Official Telephone Number:
208-397-4540

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1129RP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2349700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2019739 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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