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General NPI Number Information
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NPI Number | 1164938130
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Entity Type | Individual
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Provider Name | DONNA C. WALLACE PHARMD
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Gender | Female
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Dates
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Enumeration Date | 12/28/2017
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Last Update Date | 12/28/2017
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Provider Practice Location Address
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Address Line | 1817 NW 127TH AVE
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City | PEMBROKE PINES
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State | FL
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Zip | 33028-2567
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Country | US
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Telephone | 954-325-1495
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Fax |
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Provider Business Mailing Address
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Address Line | 1817 NW 127TH AVE
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City | PEMBROKE PINES
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State | FL
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Zip | 33028-2567
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Country | US
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Telephone | 954-325-1495
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P2201X
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Taxonomy Name | Ambulatory Care Pharmacist
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License Number | PU4665
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PS30769
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License Number State | FL
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