Healthcare Provider Details

I. General information

NPI: 1295690550
Provider Name (Legal Business Name): BRIELL WALLACE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14252 US 301 S
RIVERVIEW FL
33578-9349
US

IV. Provider business mailing address

14252 US 301 S
RIVERVIEW FL
33578-9349
US

V. Phone/Fax

Practice location:
  • Phone: 813-922-7676
  • Fax:
Mailing address:
  • Phone: 813-922-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number69803
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: