Provider Demographics
NPI:1376632067
Name:WALLS ALTRU PHARMACY INC
Entity Type:Organization
Organization Name:WALLS ALTRU PHARMACY INC
Other - Org Name:WALLS HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-746-0497
Mailing Address - Street 1:4440 S WASHINGTON ST
Mailing Address - Street 2:STE 101D
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7245
Mailing Address - Country:US
Mailing Address - Phone:701-732-2900
Mailing Address - Fax:701-732-2909
Practice Address - Street 1:4440 S WASHINGTON ST
Practice Address - Street 2:STE 101D
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7245
Practice Address - Country:US
Practice Address - Phone:701-732-2900
Practice Address - Fax:701-732-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2641793336C0002X
NDPHAR8153336C0003X
3336C0004X, 3336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21479Medicaid
MN734967100Medicaid
2071617OtherPK
MN734967100Medicaid