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
- 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 and National Provider Directory roles.
-
- Community/Retail Pharmacy
- Aberdeen, ID
- NPI 1710038716
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.