Provider Demographics
NPI:1235424516
Name:WALLACE, JACK BROWNING (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BROWNING
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 STEPHEN RD APT B
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4667
Mailing Address - Country:US
Mailing Address - Phone:831-332-9593
Mailing Address - Fax:
Practice Address - Street 1:901 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2122
Practice Address - Country:US
Practice Address - Phone:831-426-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist