Active NPI
Mark James Wallace, DOCTOR OF PHARMACY
- Pharmacist
- Edmond, OK
National Provider Identifier
1205110434
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 11913
- Practice address
- 301 S Sante Fe Ave
Edmond, OK 73003 - Phone
- (405) 330-6093
- Fax
- (405) 330-6153
- NPI assigned
- Oct 6, 2011
- Sex
- Male
- Sole proprietor
- No
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 | 11913 | OK | Primary |
Addresses
Primary practice location
301 S Sante Fe Ave
Edmond, OK 73003
Mailing address
301 S Sante Fe Ave
Edmond, OK 73003
Phone (405) 330-6093
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
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11913 | OK | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Organizations & group practices 2
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.
-
- Pharmacy
- Edmond, OK
- NPI 1134134190
-
- Pharmacy
- Longview, TX
- NPI 1629956545
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1317859200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1317859200000",
"number": "1205110434",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "301 S SANTE FE AVE",
"city": "EDMOND",
"state": "OK",
"postal_code": "73003",
"telephone_number": "405-330-6093",
"fax_number": "405-330-6153"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "301 S SANTE FE AVE",
"city": "EDMOND",
"state": "OK",
"postal_code": "73003",
"telephone_number": "405-330-6093",
"fax_number": "405-330-6153"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "MARK",
"middle_name": "JAMES",
"name_prefix": "Mr.",
"credential": "DOCTOR OF PHARMACY",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-10-06",
"last_updated": "2011-10-06",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "OK",
"license": "11913",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Edmond, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 6, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.