Provider Demographics
NPI:1154678332
Name:WALLACE, RICHARD PAUL (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:PAUL
Last Name:WALLACE
Suffix:
Gender:M
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:PSC 80
Mailing Address - Street 2:BOX 13059
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 80
Practice Address - Street 2:BOX 13059
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96367-9998
Practice Address - Country:US
Practice Address - Phone:0804-797-7955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH04611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist