Provider Demographics
NPI:1316547342
Name:WALLACE, THOMAS E III (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 BEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2938
Mailing Address - Country:US
Mailing Address - Phone:917-932-4257
Mailing Address - Fax:
Practice Address - Street 1:1571 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2226
Practice Address - Country:US
Practice Address - Phone:718-720-5604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0015303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist