Healthcare Provider Details

I. General information

NPI: 1215892526
Provider Name (Legal Business Name): CARA LYNEE WALLACE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

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

100 JASON DR
TROY MO
63379-1944
US

IV. Provider business mailing address

333 N 30TH ST
LOUISIANA MO
63353-2507
US

V. Phone/Fax

Practice location:
  • Phone: 636-462-5901
  • Fax: 636-462-5902
Mailing address:
  • Phone: 636-357-8423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number044711
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: