Provider Demographics
NPI:1194524611
Name:WALLACE, HAYLEY
Entity type:Individual
Prefix:
First Name:HAYLEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9953 STONE RD
Mailing Address - Street 2:
Mailing Address - City:MAYBEE
Mailing Address - State:MI
Mailing Address - Zip Code:48159-9761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1247
Practice Address - Country:US
Practice Address - Phone:734-439-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302417313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist