Provider Demographics
NPI:1548590441
Name:WALLACE, SUZI ANN (BS PHARMACY)
Entity Type:Individual
Prefix:MRS
First Name:SUZI
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BS PHARMACY
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Other - Credentials:
Mailing Address - Street 1:1 DEACONESS RD
Mailing Address - Street 2:WEST CAMPUS IND PHARMACY CCB-011
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5321
Mailing Address - Country:US
Mailing Address - Phone:617-754-3844
Mailing Address - Fax:617-754-3845
Practice Address - Street 1:1 DEACONESS RD
Practice Address - Street 2:WEST CAMPUS IND PHARMACY CCB-011
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5321
Practice Address - Country:US
Practice Address - Phone:617-754-3844
Practice Address - Fax:617-754-3845
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPH23379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist