Provider Demographics
NPI:1639404833
Name:WALLACE, JENNIFER LEIGH (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 POPLAR TENT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-7757
Mailing Address - Country:US
Mailing Address - Phone:704-784-1977
Mailing Address - Fax:704-784-1984
Practice Address - Street 1:5230 POPLAR TENT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-7757
Practice Address - Country:US
Practice Address - Phone:704-784-1977
Practice Address - Fax:704-784-1984
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist