1972995934 NPI number — MISS TERRICA DIANE WALLACE PHARMD.

Table of content: MISS TERRICA DIANE WALLACE PHARMD. (NPI 1972995934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972995934 NPI number — MISS TERRICA DIANE WALLACE PHARMD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
TERRICA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PHARMD.
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:
1972995934
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3928 VICTORIA LAKES DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32226-0709
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:
7546 103RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32210-6713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-777-3050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2015

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:  PS52287 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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