Provider Demographics
NPI:1649986555
Name:WALLACE, BRIANNA MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MARIE
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 1:12349 S MEADE AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1834
Mailing Address - Country:US
Mailing Address - Phone:708-843-1861
Mailing Address - Fax:
Practice Address - Street 1:8700 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1024
Practice Address - Country:US
Practice Address - Phone:708-499-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.3049751835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist