Provider Demographics
NPI:1093086019
Name:WAL-MART PHARMACY STORE 3422
Entity Type:Organization
Organization Name:WAL-MART PHARMACY STORE 3422
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUAHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:856-384-6740
Mailing Address - Street 1:2000 CLEMENTS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2016
Mailing Address - Country:US
Mailing Address - Phone:856-384-6740
Mailing Address - Fax:856-384-6742
Practice Address - Street 1:2000 CLEMENTS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-2016
Practice Address - Country:US
Practice Address - Phone:856-384-6740
Practice Address - Fax:856-384-6742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28R103317000261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health