Provider Demographics
NPI:1972995934
Name:WALLACE, TERRICA DIANE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:TERRICA
Middle Name:DIANE
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 1:3928 VICTORIA LAKES DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-0709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7546 103RD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-6713
Practice Address - Country:US
Practice Address - Phone:904-777-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-28
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist