Healthcare Provider Details

I. General information

NPI: 1811279268
Provider Name (Legal Business Name): VICTORIA L WALLACE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S 8TH STREET
PAYETTE ID
83661
US

IV. Provider business mailing address

2726 S MONTAUK AVE
BOISE ID
83709-3300
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9331
  • Fax:
Mailing address:
  • Phone: 208-890-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5339
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH0009655
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: