Provider Demographics
NPI:1588444053
Name:WALLACE, JESSICA (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 ACORN ST
Mailing Address - Street 2:
Mailing Address - City:EUDORA
Mailing Address - State:KS
Mailing Address - Zip Code:66025-9681
Mailing Address - Country:US
Mailing Address - Phone:913-980-0510
Mailing Address - Fax:
Practice Address - Street 1:2200 SW GAGE BLVD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66622-0001
Practice Address - Country:US
Practice Address - Phone:785-350-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100038183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist