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General NPI Number Information
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NPI Number | 1265787147
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Entity Type | Individual
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Provider Name | THOMAS DANVILLE WALLACE CPHT
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Gender | Male
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Dates
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Enumeration Date | 07/17/2012
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Last Update Date | 07/17/2012
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Provider Practice Location Address
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Address Line | 215 DEXTER L WOODS MEMORIAL BLVD
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City | WAYNESBORO
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State | TN
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Zip | 38485-2416
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Country | US
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Telephone | 931-722-5466
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Fax |
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Provider Business Mailing Address
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Address Line | 501 HIGHWAY 64 W
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City | WAYNESBORO
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State | TN
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Zip | 38485-2355
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Country | US
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Telephone | 931-722-3605
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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 | 183700000X
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Taxonomy Name | Pharmacy Technician
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License Number | 37742
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License Number State | TN
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