Provider Demographics
NPI:1225375173
Name:WALLACE, JENNIFER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
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 1:4425 COMMONS DR E
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3414
Mailing Address - Country:US
Mailing Address - Phone:850-837-7133
Mailing Address - Fax:850-654-8959
Practice Address - Street 1:4425 COMMONS DR E
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3414
Practice Address - Country:US
Practice Address - Phone:850-837-7133
Practice Address - Fax:850-654-8959
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist