Provider Demographics
NPI:1821693896
Name:WALLACE, NATHAN ANDREW (PHARMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ANDREW
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 DARTMOOR DR
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-1617
Mailing Address - Country:US
Mailing Address - Phone:717-386-4634
Mailing Address - Fax:
Practice Address - Street 1:137 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3258
Practice Address - Country:US
Practice Address - Phone:508-478-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH236095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist