Provider Demographics
NPI:1104107838
Name:WALLACE, CAROL HENSHAW (PHARMACIST)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:HENSHAW
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:BENNETTS PHARMACY
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398
Mailing Address - Country:US
Mailing Address - Phone:931-967-2777
Mailing Address - Fax:931-967-1264
Practice Address - Street 1:1201 DINAH SHORE BOULEVARD
Practice Address - Street 2:BENNETTS PHARMACY
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398
Practice Address - Country:US
Practice Address - Phone:931-967-2777
Practice Address - Fax:931-967-1264
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000008424183500000X
TN8424332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1534061Medicaid
TN1534061Medicaid