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NPI Code Detail

MEDICARE: MR. MICHAEL WALLACE II

MEDICARE: MR. MICHAEL WALLACE II
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
1183500000XPharmacist066034NY

General Provider Information

NPI Number : 1356917553
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MICHAEL WALLACE II
Provider Business Mailing Address
First Line : 260 ARDEN AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10312-1229
Country : US
Telephone Number : 718-966-5509
Fax Number :
Provider Business Practice Location Address
First Line : 260 ARDEN AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10312-1229
Country : US
Telephone Number : 718-966-5509
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/28/2021
Last Update Date : 05/28/2021

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