MEDICARE: KENNIS HAL WALLACE JR. RPH

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811981939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNIS HAL WALLACE JR. RPH

Provider Business Mailing Address
First Line	:	303 S COMMERCIAL ST
Second Line	:	PARKER PLAZA
City	:	HARRISBURG
State	:	IL
Zip	:	62946-2125
Country	:	US
Telephone Number	:	618-253-7621
Fax Number	:	618-252-7455

Provider Business Practice Location Address
First Line	:	303 S COMMERCIAL ST
Second Line	:	PARKER PLAZA
City	:	HARRISBURG
State	:	IL
Zip	:	62946-2125
Country	:	US
Telephone Number	:	618-253-7621
Fax Number	:	618-252-7455

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	07/08/2007

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