Provider Demographics
NPI:1295339430
Name:WALLACE, AUDREY C (RPH)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 N 300 W
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5026 W US HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-9770
Practice Address - Country:US
Practice Address - Phone:317-861-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03440267183500000X
IN26029026A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist