Individual
SHANISE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3710 57TH AVE, KENOSHA, WI 53144-4820
(262) 652-1474
Mailing address
3710 57TH AVE, KENOSHA, WI 53144-4820
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
17696-40
WI
Other
Enumeration date
03/06/2020
Last updated
03/06/2020
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