Provider Demographics
NPI:1750408795
Name:WALLACE, KEITH ALAN (BS PHARM)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WOODLAND RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1788
Mailing Address - Country:US
Mailing Address - Phone:636-240-0665
Mailing Address - Fax:
Practice Address - Street 1:11643 LILBURN PARK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3535
Practice Address - Country:US
Practice Address - Phone:314-995-6843
Practice Address - Fax:888-916-0877
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001019315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist