Provider Demographics
NPI:1033971197
Name:WALLACE, KENNEDE MARISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNEDE
Middle Name:MARISSA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 NASSAU ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5513
Mailing Address - Country:US
Mailing Address - Phone:843-486-2084
Mailing Address - Fax:843-486-2084
Practice Address - Street 1:51 NASSAU ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5513
Practice Address - Country:US
Practice Address - Phone:843-486-2084
Practice Address - Fax:843-486-2084
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist