Provider Demographics
NPI:1427587690
Name:WALLACE, JENNIE ANESIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:ANESIA
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 1:228 WINDCHASE DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4640
Mailing Address - Country:US
Mailing Address - Phone:205-862-0022
Mailing Address - Fax:205-699-0715
Practice Address - Street 1:8551 WHITFIELD AVE
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:AL
Practice Address - Zip Code:35094-7560
Practice Address - Country:US
Practice Address - Phone:205-699-0677
Practice Address - Fax:205-699-0715
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist