Provider Demographics
NPI:1760039192
Name:WALLACE, KOLE
Entity Type:Individual
Prefix:
First Name:KOLE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 CHEVY CHASE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1547
Mailing Address - Country:US
Mailing Address - Phone:937-573-7039
Mailing Address - Fax:
Practice Address - Street 1:1009 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2809
Practice Address - Country:US
Practice Address - Phone:419-525-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist