Healthcare Provider Details

I. General information

NPI: 1790538015
Provider Name (Legal Business Name): JORDAN WALLACE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9981 S HEALTHPARK DR
FORT MYERS FL
33908-3618
US

IV. Provider business mailing address

9981 S HEALTHPARK DR
FORT MYERS FL
33908-3618
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9163
  • Fax: 239-343-5321
Mailing address:
  • Phone: 239-343-9163
  • Fax: 239-343-5321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number9725
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: