MEDICARE: MR. ROBERT WALLACE

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	INTERN -- 6699	AZ

General Provider Information

NPI Number	:	1750443024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT WALLACE

Provider Business Mailing Address
First Line	:	12421 W DENTON AVE
Second Line	:
City	:	LITCHFIELD PARK
State	:	AZ
Zip	:	85340-3435
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12421 W DENTON AVE
Second Line	:
City	:	LITCHFIELD PARK
State	:	AZ
Zip	:	85340-3435
Country	:	US
Telephone Number	:	623-535-9788
Fax Number	:

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. ROBERT WALLACE ” Practice Location

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