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NPI Code Detail

MEDICARE: MR. JEFFREY A. WALLACE I R.PH.

MEDICARE: MR. JEFFREY A. WALLACE I R.PH.
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
1183500000XPharmacist03-3-10464OH

General Provider Information

NPI Number : 1568499234
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JEFFREY A. WALLACE I R.PH.
Provider Business Mailing Address
First Line : 5420 LANCASTER DR
Second Line :
City : BROOKLYN HEIGHTS
State : OH
Zip : 44131-1832
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5420 LANCASTER DR
Second Line : KAISER PERMANENTE PHARMACY ADMINISTRATION
City : BROOKLYN HEIGHTS
State : OH
Zip : 44131-1832
Country : US
Telephone Number : 216-749-8408
Fax Number : 216-749-8426
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/27/2006
Last Update Date : 07/08/2007

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