Provider Demographics
NPI:1306204144
Name:WALLACE, EMILY BROOKE (PHARMD CANDIDATE)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BROOKE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARMD CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 NE WESTWOOD DR APT H103
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5233
Mailing Address - Country:US
Mailing Address - Phone:406-579-7205
Mailing Address - Fax:
Practice Address - Street 1:2290 NE WESTWOOD DR APT H103
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5233
Practice Address - Country:US
Practice Address - Phone:406-579-7205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60302033183500000X
IDE34399183500000X
MTPHA-PIN-LIC-15878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist