Provider Demographics
NPI:1316722259
Name:WALLACE, BRYCE ALEXANDER (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:ALEXANDER
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 1:101 RICHLAND RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-9102
Mailing Address - Country:US
Mailing Address - Phone:573-724-2627
Mailing Address - Fax:
Practice Address - Street 1:222 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1614
Practice Address - Country:US
Practice Address - Phone:573-379-5460
Practice Address - Fax:573-379-5459
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021038939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist