MEDICARE: CLARISSA WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	40012	TX

General Provider Information

NPI Number	:	1780996314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA WALLACE

Provider Business Mailing Address
First Line	:	3663 BRIARPARK DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77042-5205
Country	:	US
Telephone Number	:	713-268-3630
Fax Number	:	623-869-1717

Provider Business Practice Location Address
First Line	:	3300 BEE CAVE RD STE 500
Second Line	:
City	:	WEST LAKE HILLS
State	:	TX
Zip	:	78746-6770
Country	:	US
Telephone Number	:	512-329-7408
Fax Number	:	512-329-7411

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2010
Last Update Date	:	07/12/2010

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Directions to “ CLARISSA WALLACE ” Practice Location

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