Provider Demographics
NPI:1568241768
Name:WALLACE, ALEXANDRIA LYNN (CPHT)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRIA
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:DR
Other - First Name:ALEXANDRIA
Other - Middle Name:LYNN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ALEXANDRIA WALLACE
Mailing Address - Street 1:103 TURTLE CRK
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2896
Mailing Address - Country:US
Mailing Address - Phone:210-997-6770
Mailing Address - Fax:
Practice Address - Street 1:24165 IH 10 W STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1161
Practice Address - Country:US
Practice Address - Phone:210-687-1072
Practice Address - Fax:210-568-4920
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX269783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist