Healthcare Provider Details

I. General information

NPI: 1518051523
Provider Name (Legal Business Name): MARILYNN R. WALLACE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 PERRY HILL RD CAVHCS-119
MONTGOMERY AL
36109
US

IV. Provider business mailing address

6417 WYNWOOD PLACE
MONTGOMERY AL
36117
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-4670
  • Fax:
Mailing address:
  • Phone: 334-272-4670
  • Fax: 334-260-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11078
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: