Provider Demographics
NPI:1811981939
Name:WALLACE, KENNIS HAL JR (RPH)
Entity type:Individual
Prefix:
First Name:KENNIS
Middle Name:HAL
Last Name:WALLACE
Suffix:JR
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 1:303 S COMMERCIAL ST
Mailing Address - Street 2:PARKER PLAZA
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2125
Mailing Address - Country:US
Mailing Address - Phone:618-253-7621
Mailing Address - Fax:618-252-7455
Practice Address - Street 1:303 S COMMERCIAL ST
Practice Address - Street 2:PARKER PLAZA
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2125
Practice Address - Country:US
Practice Address - Phone:618-253-7621
Practice Address - Fax:618-252-7455
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370921467001Medicaid
648470Medicare UPIN
IL370921467001Medicaid