Provider Demographics
NPI:1750484952
Name:WALLACE, CHAD A (RPH)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:WALLACE
Suffix:
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 1:112 MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8925
Mailing Address - Country:US
Mailing Address - Phone:304-562-1821
Mailing Address - Fax:304-720-6963
Practice Address - Street 1:208 ROXALANA BUSINESS PARK
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-2727
Practice Address - Country:US
Practice Address - Phone:304-720-6970
Practice Address - Fax:304-720-6963
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005705183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist