Provider Demographics
NPI:1609085232
Name:WALLACE, SHAWN CORBET (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:CORBET
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 1:471 HIGHLANDS LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5393
Mailing Address - Country:US
Mailing Address - Phone:770-592-1707
Mailing Address - Fax:
Practice Address - Street 1:954 JOE FRANK HARRIS PKWY SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2129
Practice Address - Country:US
Practice Address - Phone:770-383-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist