Provider Demographics
NPI:1093117988
Name:WALLACE, JOANNA THERESA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:THERESA
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 1:280 ROUTE 211 E
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-3109
Mailing Address - Country:US
Mailing Address - Phone:845-341-2700
Mailing Address - Fax:845-402-7039
Practice Address - Street 1:280 ROUTE 211 E
Practice Address - Street 2:SUITE 112
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3109
Practice Address - Country:US
Practice Address - Phone:845-341-2700
Practice Address - Fax:845-402-7039
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234197183500000X
NY059150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist