Provider Demographics
NPI:1497447247
Name:BRUESTLE-WALLACE, KAREN ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ELIZABETH
Last Name:BRUESTLE-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 1:4996 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4506
Mailing Address - Country:US
Mailing Address - Phone:336-666-0093
Mailing Address - Fax:
Practice Address - Street 1:4996 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4506
Practice Address - Country:US
Practice Address - Phone:336-774-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11872183500000X
TN40764183500000X
FLPS25711183500000X
NC27331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist