Provider Demographics
NPI:1518578467
Name:WALLACE, DYLAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DYLAN
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 1:515 S MANGUM ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-4384
Mailing Address - Country:US
Mailing Address - Phone:336-583-8170
Mailing Address - Fax:
Practice Address - Street 1:1106 ENVIRON WAY
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-4418
Practice Address - Country:US
Practice Address - Phone:919-942-8738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist