Provider Demographics
NPI:1225341753
Name:NDUATI, WALLACE G (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:G
Last Name:NDUATI
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 1:38 CHILMARK ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-2844
Mailing Address - Country:US
Mailing Address - Phone:774-232-5278
Mailing Address - Fax:
Practice Address - Street 1:38 CHILMARK ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-2844
Practice Address - Country:US
Practice Address - Phone:774-232-5278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist