Healthcare Provider Details

I. General information

NPI: 1710038716
Provider Name (Legal Business Name): WALLACE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S MAIN
ABERDEEN ID
83210-0841
US

IV. Provider business mailing address

44 S MAIN PO BOX 841
ABERDEEN ID
83210-0841
US

V. Phone/Fax

Practice location:
  • Phone: 208-397-4540
  • Fax: 208-397-5215
Mailing address:
  • Phone: 208-397-4540
  • Fax: 208-397-5215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1129RP
License Number StateID

VIII. Authorized Official

Name: DWIGHT WALLACE
Title or Position: CEO/PIC
Credential: PHARMD
Phone: 208-397-4540