Individual
CORY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHARMD
Contact information
Practice address
2301 W KENOSHA ST, BROKEN ARROW, OK 74012-8912
(918) 259-9136
Mailing address
11005 S JOPLIN PL, TULSA, OK 74137-5023
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
14955
OK
Other
Enumeration date
10/29/2020
Last updated
10/29/2020
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