Provider Demographics
NPI:1063175842
Name:WALLACE, JOVANTE ANTWON (PHARMD)
Entity type:Individual
Prefix:
First Name:JOVANTE
Middle Name:ANTWON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 OAKTON DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-7105
Mailing Address - Country:US
Mailing Address - Phone:904-423-7863
Mailing Address - Fax:
Practice Address - Street 1:83 OAKTON DR
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-7105
Practice Address - Country:US
Practice Address - Phone:904-423-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19222-40183500000X
WI26027447A183500000X
TX65475183500000X
IL051300907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist