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General NPI Number Information
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NPI Number | 1497447247
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Entity Type | Individual
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Provider Name | KAREN ELIZABETH BRUESTLE-WALLACE PHARMD
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Gender | Female
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Dates
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Enumeration Date | 05/22/2023
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Last Update Date | 05/22/2023
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Provider Practice Location Address
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Address Line | 4996 COUNTRY CLUB RD
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City | WINSTON SALEM
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State | NC
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Zip | 27104-4506
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Country | US
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Telephone | 336-774-8420
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Fax |
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Provider Business Mailing Address
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Address Line | 4996 COUNTRY CLUB RD
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City | WINSTON SALEM
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State | NC
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Zip | 27104-4506
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Country | US
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Telephone | 336-666-0093
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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 | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 11872
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License Number State | AL
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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 | 40764
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PS25711
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 27331
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License Number State | NC
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