Provider Demographics
NPI:1356917553
Name:WALLACE, MICHAEL II
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WALLACE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:E
Other - Last Name:WALLACE
Other - Suffix:II
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:260 ARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1229
Mailing Address - Country:US
Mailing Address - Phone:718-966-5509
Mailing Address - Fax:
Practice Address - Street 1:260 ARDEN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1229
Practice Address - Country:US
Practice Address - Phone:718-966-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist