MEDICARE: DR. JACK BROWNING WALLACE PHARM. D

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	33200	CA

General Provider Information

NPI Number	:	1235424516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK BROWNING WALLACE PHARM. D

Provider Business Mailing Address
First Line	:	151 STEPHEN RD APT B
Second Line	:
City	:	APTOS
State	:	CA
Zip	:	95003-4667
Country	:	US
Telephone Number	:	831-332-9593
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 SOQUEL AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-2122
Country	:	US
Telephone Number	:	831-426-4303
Fax Number	:

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

Provider Enumeration Date	:	06/14/2011
Last Update Date	:	06/14/2011

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