NPIMap

Organization Active NPI

Wallace Pharmacy Inc

Doing business as Wallace Drug

  • Community/Retail Pharmacy
  • Aberdeen, ID
National Provider Identifier
1710038716
Registry record updated Mar 10, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
1129RP Issued in ID
Legal business name
WALLACE PHARMACY INC
Doing business as
Wallace Drug
Practice address
44 S Main
Aberdeen, ID 83210-0841
Phone
(208) 397-4540
Fax
(208) 397-5215
NPI assigned
Jan 16, 2007
Last updated
Mar 10, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 10, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dwight Wallace, PHARMDNPI 1104245620
Title
Ceo/Pic
Phone
(208) 397-4540

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X NU
Community/Retail Pharmacy 3336C0003X 1129RP ID Primary

Addresses

Primary practice location

44 S Main
Aberdeen, ID 83210-0841

Mailing address

44 S Main
PO Box 841
Aberdeen, ID 83210-0841
Phone (208) 397-4540

Other identifiers 2

IdentifierTypeStateIssuer
2019739OtherPK
2349700MedicaidID

Other names 1

  • WALLACE DRUG Doing business as

National Provider Directory

National Provider Directory

Locations

44 S Main St
Aberdeen, ID 83210
Phone (208) 397-4540

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168905600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1489104000000",
    "number": "1710038716",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "44 S MAIN",
            "address_2": "PO BOX 841",
            "city": "ABERDEEN",
            "state": "ID",
            "postal_code": "832100841",
            "telephone_number": "208-397-4540",
            "fax_number": "208-397-5215"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "44 S MAIN",
            "city": "ABERDEEN",
            "state": "ID",
            "postal_code": "832100841",
            "telephone_number": "208-397-4540",
            "fax_number": "208-397-5215"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLACE PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-16",
        "last_updated": "2017-03-10",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "DWIGHT",
        "authorized_official_title_or_position": "CEO/PIC",
        "authorized_official_telephone_number": "208-397-4540",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "1129RP",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2019739",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2349700",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WALLACE DRUG",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Mar 10, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.