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General NPI Number Information
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NPI Number | 1568749026
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Entity Type | Individual
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Provider Name | KRISTIN RENEE WALLACE PHARM.D.
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Gender | Female
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Dates
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Enumeration Date | 11/11/2011
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Last Update Date | 08/28/2025
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Provider Practice Location Address
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Address Line | 1650 COCHRANE CIRCLE OUTPATIENT PHARMACY
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City | FORT CARSON
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State | CO
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Zip | 80913
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Country | US
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Telephone | 719-524-4410
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Fax |
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Provider Business Mailing Address
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Address Line | 1485 SOLITAIRE ST
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City | COLORADO SPRINGS
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State | CO
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Zip | 80905-4255
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Country | US
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Telephone | 805-717-3743
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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 | 16808
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License Number State | CO
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