Provider Demographics
NPI:1336282821
Name:WALMART
Entity Type:Organization
Organization Name:WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:334-702-0840
Mailing Address - Street 1:3300 S OATES ST
Mailing Address - Street 2:ATTN PHARMACY
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-5694
Mailing Address - Country:US
Mailing Address - Phone:334-702-0840
Mailing Address - Fax:334-702-0580
Practice Address - Street 1:3300 S OATES ST
Practice Address - Street 2:ATTN PHARMACY
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5694
Practice Address - Country:US
Practice Address - Phone:334-702-0840
Practice Address - Fax:334-702-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL111072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid