Individual
KEITH ALAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BS PHARM
Contact information
Practice address
11643 LILBURN PARK RD, SAINT LOUIS, MO 63146-3535
(314) 995-6843
(888) 916-0877
Mailing address
5 WOODLAND RIDGE CT, SAINT PETERS, MO 63376-1788
(636) 240-0665
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
2001019315
MO
Other
Enumeration date
03/23/2007
Last updated
01/14/2011
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