Provider Demographics
NPI:1326639006
Name:WALLACE, DUSTIN L (CPHT)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2952 ROSSELLE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-5666
Mailing Address - Country:US
Mailing Address - Phone:615-310-1217
Mailing Address - Fax:888-974-6157
Practice Address - Street 1:2 SHIRCLIFF WAY STE 900
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4753
Practice Address - Country:US
Practice Address - Phone:904-389-9744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT57955183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRPT57955OtherPHARMACY TECH