Healthcare Provider Details

I. General information

NPI: 1104245620
Provider Name (Legal Business Name): DWIGHT D. WALLACE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S. MAIN ST
ABERDEEN ID
83210
US

IV. Provider business mailing address

PO BOX 841
ABERDEEN ID
83210-0841
US

V. Phone/Fax

Practice location:
  • Phone: 208-397-4540
  • Fax:
Mailing address:
  • Phone: 208-397-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4895
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: