Provider Demographics
NPI:1598368938
Name:WALLACE, BETHANY GAY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:GAY
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 1:12 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-8595
Mailing Address - Country:US
Mailing Address - Phone:812-449-9470
Mailing Address - Fax:
Practice Address - Street 1:1405 OAK ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1215
Practice Address - Country:US
Practice Address - Phone:304-453-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist