Healthcare Provider Details

I. General information

NPI: 1962581702
Provider Name (Legal Business Name): CAROL H WALLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 DINAH SHORE BOULEVARD
WINCHESTER TN
37398
US

IV. Provider business mailing address

PO BOX 70 1201 DINAH SHORE BOULEVARD
WINCHESTER TN
37398
US

V. Phone/Fax

Practice location:
  • Phone: 931-967-2777
  • Fax: 931-967-1264
Mailing address:
  • Phone: 931-967-2777
  • Fax: 931-967-1264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000001203
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CAROL WALLACE
Title or Position: PIC OWNER
Credential: PHARM.D
Phone: 931-967-2777