Provider Demographics
NPI:1992282032
Name:HARTY WALLACE, JEAN (RPH)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:HARTY WALLACE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11420 LACKLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3561
Mailing Address - Country:US
Mailing Address - Phone:314-994-9900
Mailing Address - Fax:
Practice Address - Street 1:11420 LACKLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3559
Practice Address - Country:US
Practice Address - Phone:314-994-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist