Healthcare Provider Details

I. General information

NPI: 1942111059
Provider Name (Legal Business Name): SARAH LYDIA WALLACE PHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SADIE WALLACE

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 LOTT CT
WEST COLUMBIA SC
29169-3051
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
US

V. Phone/Fax

Practice location:
  • Phone: 803-719-4050
  • Fax: 803-719-4054
Mailing address:
  • Phone: 833-510-4357
  • Fax: 866-460-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number58493
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: