Provider Demographics
NPI:1669794764
Name:WALLACE, PAUL JOHN (RPH)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 PUMPERNICKEL LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8639
Mailing Address - Country:US
Mailing Address - Phone:704-291-7805
Mailing Address - Fax:
Practice Address - Street 1:1993 DICKERSON BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2795
Practice Address - Country:US
Practice Address - Phone:704-296-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15840183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist