Provider Demographics
NPI:1245324714
Name:WALLACE, ANITA L (PHARMD, CGP)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARMD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HAWTHORNE DR
Mailing Address - Street 2:F-303
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6895
Mailing Address - Country:US
Mailing Address - Phone:603-703-3660
Mailing Address - Fax:
Practice Address - Street 1:MANCHESTER VA MEDICAL CENTER
Practice Address - Street 2:718 SMYTH ROAD
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03110
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000010344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist