Provider Demographics
NPI:1477943223
Name:WALLACE, STEPHANIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
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 1:815 CHEYENNE MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4929
Mailing Address - Country:US
Mailing Address - Phone:719-527-1640
Mailing Address - Fax:
Practice Address - Street 1:815 CHEYENNE MEADOWS RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4929
Practice Address - Country:US
Practice Address - Phone:719-527-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058853183500000X
TN33624183500000X
CO0020679183500000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist