Provider Demographics
NPI:1265787147
Name:WALLACE, THOMAS DANVILLE (CPHT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DANVILLE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 HIGHWAY 64 W
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-2355
Mailing Address - Country:US
Mailing Address - Phone:931-722-3605
Mailing Address - Fax:
Practice Address - Street 1:215 DEXTER L WOODS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2416
Practice Address - Country:US
Practice Address - Phone:931-722-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37742183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician