Provider Demographics
NPI:1760767438
Name:WALLACE, ELIZABETH ASHLEY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name: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:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-0279
Mailing Address - Country:US
Mailing Address - Phone:704-896-0555
Mailing Address - Fax:704-987-1784
Practice Address - Street 1:127 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8096
Practice Address - Country:US
Practice Address - Phone:704-896-0555
Practice Address - Fax:704-987-1784
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist