Most Relevant Information
Provider Data
| NPI Number: | 1003241571 |
| Provider Name: | MICAH JORDAN WALLACE PHARM.D. |
| Entity Type: | Individual |
| Taxonomy Code: | 183500000X |
| Specialty: | Pharmacist |
| License Number: | 14060 |
Most Important Dates
| Enumeration Date: | 09/03/2013 |
| Last Updated: | 09/03/2013 |
Provider Practice Location
2152 SAVANNAH HWY
CHARLESTON
SC
294145311
Practice Location Phone/Fax
| Phone: | 8435568974 |
| Fax: |
Provider Mailing Location
2152 SAVANNAH HWY
CHARLESTON
SC
294145311
Provider Mailing Phone/Fax
| Phone: | 8435568974 |
| Fax: |