Provider Demographics
NPI:1689739211
Name:WALLACE, DIANE ELIZABETH (RPH)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 WASATCH DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2472
Mailing Address - Country:US
Mailing Address - Phone:801-582-8909
Mailing Address - Fax:801-565-2306
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:ROOM 1400
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-2276
Practice Address - Fax:801-585-2306
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1433401701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist