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General NPI Number Information
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NPI Number | 1619344074
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Entity Type | Individual
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Provider Name | JEANETTE WALLACE RPH
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Gender | Female
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Dates
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Enumeration Date | 09/01/2015
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Last Update Date | 07/29/2019
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Provider Practice Location Address
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Address Line | 9040 JACKSON AVE
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City | TACOMA
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State | WA
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Zip | 98431-6456
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Country | US
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Telephone | 253-968-2252
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Fax |
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Provider Business Mailing Address
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Address Line | 21508 107TH AVE E
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City | GRAHAM
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State | WA
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Zip | 98338-6456
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Country | US
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Telephone | 253-653-8659
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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 | PH00015991
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License Number State | WA
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