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General NPI Number Information
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NPI Number | 1982296877
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Entity Type | Individual
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Provider Name | TYSON WALLACE PHARM. D.
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Gender | Male
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Dates
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Enumeration Date | 02/11/2021
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 134 BEVILL AVE
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City | GOSNELL
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State | AR
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Zip | 72315
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Country | US
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Telephone | 870-751-9242
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Fax | 870-751-9291
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Provider Business Mailing Address
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Address Line | 134 BEVILL AVE
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City | GOSNELL
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State | AR
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Zip | 72315
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Country | US
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Telephone | 870-751-9242
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Fax | 870-751-9291
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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 | 2007005629
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License Number State | MO
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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 | PD09924
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License Number State | AR
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