Provider Demographics
NPI:1023619061
Name:WALLACE, STEPHANIE LYNN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SANDY ST
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-2002
Mailing Address - Country:US
Mailing Address - Phone:606-899-5738
Mailing Address - Fax:
Practice Address - Street 1:254 CASSIDY BLVD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1426
Practice Address - Country:US
Practice Address - Phone:606-432-6180
Practice Address - Fax:606-432-6182
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist