Provider Demographics
NPI:1023560166
Name:SAM'S CLUB/WALMART
Entity Type:Organization
Organization Name:SAM'S CLUB/WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RELIEF STAFF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:THANHVAN
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:480-364-1568
Mailing Address - Street 1:4038 N TERRA MESA CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1475
Mailing Address - Country:US
Mailing Address - Phone:480-364-1568
Mailing Address - Fax:
Practice Address - Street 1:1375 S ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6500
Practice Address - Country:US
Practice Address - Phone:480-364-1568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0130763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy