Provider Demographics
NPI:1114592714
Name:WALLACE, LARIQUE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LARIQUE
Middle Name:
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 1:780 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3832
Mailing Address - Country:US
Mailing Address - Phone:203-353-9117
Mailing Address - Fax:
Practice Address - Street 1:780 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3832
Practice Address - Country:US
Practice Address - Phone:203-353-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0015392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist