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General NPI Number Information
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NPI Number | 1750408795
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Entity Type | Individual
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Provider Name | KEITH ALAN WALLACE BS PHARM
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Gender | Male
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 01/14/2011
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Provider Practice Location Address
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Address Line | 11643 LILBURN PARK RD
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City | SAINT LOUIS
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State | MO
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Zip | 63146-3535
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Country | US
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Telephone | 314-995-6843
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Fax | 888-916-0877
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Provider Business Mailing Address
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Address Line | 5 WOODLAND RIDGE CT
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City | SAINT PETERS
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State | MO
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Zip | 63376-1788
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Country | US
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Telephone | 636-240-0665
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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 | 2001019315
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License Number State | MO
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