Individual
JOVANTE ANTWON WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHARM.D.
Contact information
Practice address
83 OAKTON DR, LOMBARD, IL 60148-7105
(904) 423-7863
Mailing address
83 OAKTON DR, LOMBARD, IL 60148-7105
(904) 423-7863
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
051300907
IL
183500000X
Pharmacist
19222-40
WI
183500000X
Pharmacist
26027447A
WI
183500000X
Pharmacist
65475
TX
Other
Enumeration date
10/18/2021
Last updated
10/18/2021
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