MEDICARE: DR. JOANNA THERESA WALLACE PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH234197	MA
2	183500000X	Pharmacist	059150	NY

General Provider Information

NPI Number	:	1093117988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOANNA THERESA WALLACE PHARMD

Provider Business Mailing Address
First Line	:	280 ROUTE 211 E
Second Line	:	SUITE 112
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-3109
Country	:	US
Telephone Number	:	845-341-2700
Fax Number	:	845-402-7039

Provider Business Practice Location Address
First Line	:	280 ROUTE 211 E
Second Line	:	SUITE 112
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-3109
Country	:	US
Telephone Number	:	845-341-2700
Fax Number	:	845-402-7039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	09/23/2014

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