=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184728149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J WALLACE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302A BARNES RD
-----------------------------------------------------
City | WILLIAMSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41097-9483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-824-4239
-----------------------------------------------------
Fax | 859-824-2110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 BARNES RD
-----------------------------------------------------
City | WILLIAMSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41097-9483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-824-4239
-----------------------------------------------------
Fax | 859-824-2110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JASON WALLACE
-----------------------------------------------------
Credential | PHARMD, RPH
-----------------------------------------------------
Telephone | 859-824-4239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | P06979
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PO6979
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------