Provider Demographics
NPI:1275938185
Name:WALLACE, MICHELLE MAYER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MAYER
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 1:2413 HIGHWAY 431 NORTH
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36206
Mailing Address - Country:US
Mailing Address - Phone:256-820-6901
Mailing Address - Fax:
Practice Address - Street 1:2413 HIGHWAY 431 NORTH
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36206
Practice Address - Country:US
Practice Address - Phone:256-820-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist