Healthcare Provider Details

I. General information

NPI: 1396950259
Provider Name (Legal Business Name): JULIET C WALLACE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N PORTER AVE
NORMAN OK
73071-6404
US

IV. Provider business mailing address

2500 SW 83RD ST
OKLAHOMA CITY OK
73159-5733
US

V. Phone/Fax

Practice location:
  • Phone: 405-307-1940
  • Fax: 405-307-1961
Mailing address:
  • Phone: 405-686-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11375
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: