Provider Demographics
NPI:1629224456
Name:COSTA-WALLACE, TARA LEE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEE
Last Name:COSTA-WALLACE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 METACOM AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-5182
Mailing Address - Country:US
Mailing Address - Phone:401-253-2723
Mailing Address - Fax:401-253-3980
Practice Address - Street 1:580 METACOM AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-5182
Practice Address - Country:US
Practice Address - Phone:401-253-2723
Practice Address - Fax:401-253-3980
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH03692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist