Provider Demographics
NPI:1093098063
Name:MEACHEAM WALLACE, KRISTIE L (RPH)
Entity Type:Individual
Prefix:MS
First Name:KRISTIE
Middle Name:L
Last Name:MEACHEAM WALLACE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 E MARYLAND CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2982
Mailing Address - Country:US
Mailing Address - Phone:417-890-7093
Mailing Address - Fax:
Practice Address - Street 1:2004 W MARLER LN
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7661
Practice Address - Country:US
Practice Address - Phone:417-581-3288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist