Provider Demographics
NPI:1871516559
Name:WALLACE, STEPHANIE RUTLEDGE (RPH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RUTLEDGE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:DENISE
Other - Last Name:RUTLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14480 SW 37TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3790
Mailing Address - Country:US
Mailing Address - Phone:954-499-1713
Mailing Address - Fax:954-499-1714
Practice Address - Street 1:2216 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6702
Practice Address - Country:US
Practice Address - Phone:954-926-2914
Practice Address - Fax:954-926-2957
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist