Provider Demographics
NPI:1952609539
Name:WALLACE, DAVID LAWRENCE JR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 BROOKLAWN ST
Mailing Address - Street 2:
Mailing Address - City:FARRAGUT
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2875
Mailing Address - Country:US
Mailing Address - Phone:865-671-7920
Mailing Address - Fax:
Practice Address - Street 1:189 BROOKLAWN ST
Practice Address - Street 2:
Practice Address - City:FARRAGUT
Practice Address - State:TN
Practice Address - Zip Code:37934-2875
Practice Address - Country:US
Practice Address - Phone:865-671-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist