Active NPI
Dwight D. Wallace, PHARMD
- Pharmacist
- Aberdeen, ID
National Provider Identifier
1104245620
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- P4895
- Practice address
- 44 S. Main St
Aberdeen, ID 83210 - Phone
- (208) 397-4540
- NPI assigned
- Apr 11, 2014
- Last updated
- Apr 11, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | P4895 | ID | Primary |
Addresses
Primary practice location
44 S. Main St
Aberdeen, ID 83210
Mailing address
PO Box 841
Aberdeen, ID 83210-0841
Phone (208) 397-4540
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Pharmacy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| P4895 | ID | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wallace Pharmacy Inc | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1397174400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1397174400000",
"number": "1104245620",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 841",
"city": "ABERDEEN",
"state": "ID",
"postal_code": "832100841",
"telephone_number": "208-397-4540"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "44 S. MAIN ST",
"city": "ABERDEEN",
"state": "ID",
"postal_code": "83210",
"telephone_number": "208-397-4540"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "DWIGHT",
"middle_name": "D.",
"credential": "PHARMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2014-04-11",
"last_updated": "2014-04-11",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "ID",
"license": "P4895",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Aberdeen, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.