MEDICARE: MR. BRENT WALLACE 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
1	183500000X	Pharmacist	03122556	OH

General Provider Information

NPI Number	:	1912321571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENT WALLACE R.PH.

Provider Business Mailing Address
First Line	:	1661 HILLIARD ROME RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-9485
Country	:	US
Telephone Number	:	614-771-9200
Fax Number	:	614-529-5165

Provider Business Practice Location Address
First Line	:	1661 HILLIARD ROME RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-9485
Country	:	US
Telephone Number	:	614-771-9200
Fax Number	:	614-529-5165

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

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	02/18/2014

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