1629224456 NPI number — MRS. TARA LEE COSTA-WALLACE PHARMD

Table of content: MRS. TARA LEE COSTA-WALLACE PHARMD (NPI 1629224456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629224456 NPI number — MRS. TARA LEE COSTA-WALLACE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTA-WALLACE
Provider First Name:
TARA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629224456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 METACOM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02809-5182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-253-2723
Provider Business Mailing Address Fax Number:
401-253-3980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 METACOM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02809-5182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-253-2723
Provider Business Practice Location Address Fax Number:
401-253-3980
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH03692 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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