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General NPI Number Information
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NPI Number | 1578859989
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Entity Type | Individual
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Provider Name | STEPHANIE A WALLGREN PHARM.D.
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Gender | Female
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Dates
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Enumeration Date | 06/23/2011
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Last Update Date | 06/03/2016
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Provider Practice Location Address
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Address Line | 4315 EL SALVADOR WAY 7TH SFG TMDC
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City | EGLIN AFB
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State | FL
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Zip | 32542-1711
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Country | US
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Telephone | 850-885-7555
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Fax |
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Provider Business Mailing Address
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Address Line | 2836 PEAR ORCHARD BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32539-5612
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Country | US
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Telephone |
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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 | 1835P0018X
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Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
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License Number | 21125
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License Number State | NC
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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 | 21125
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License Number State | NC
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