Provider Demographics
NPI:1316227051
Name:WALLACE, HEATHER FREEMAN
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:FREEMAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:BESSEMER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28016-9711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 W TRADE ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1544
Practice Address - Country:US
Practice Address - Phone:704-922-7187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist