Provider Demographics
NPI:1437402153
Name:WALLACE, TRAVIS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:WALLACE
Suffix:
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 1:1526 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-8363
Mailing Address - Country:US
Mailing Address - Phone:919-552-1126
Mailing Address - Fax:919-552-6017
Practice Address - Street 1:1526 BROAD ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-8363
Practice Address - Country:US
Practice Address - Phone:919-552-1126
Practice Address - Fax:919-552-6017
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist