Provider Demographics
NPI:1568499234
Name:WALLACE, JEFFREY A I (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:WALLACE
Suffix:I
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44131-1832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5420 LANCASTER DR
Practice Address - Street 2:KAISER PERMANENTE PHARMACY ADMINISTRATION
Practice Address - City:BROOKLYN HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44131-1832
Practice Address - Country:US
Practice Address - Phone:216-749-8408
Practice Address - Fax:216-749-8426
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-10464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist