Provider Demographics
NPI:1376899716
Name:WALLACE, RENEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
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 1:1046 S KIRKWOOD RD
Mailing Address - Street 2:T-1279
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1046 S KIRKWOOD RD
Practice Address - Street 2:T-1279
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-7200
Practice Address - Country:US
Practice Address - Phone:314-822-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026473183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist