Provider Demographics
NPI:1962581702
Name:CAROL H WALLACE
Entity type:Organization
Organization Name:CAROL H WALLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:931-967-2777
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:1201 DINAH SHORE BOULEVARD
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
TN00000012033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094785OtherPK
TN1534061Medicaid
TN103G739140Medicare PIN
TNP01587154Medicare PIN
TN1534061Medicaid