Provider Demographics
NPI:1396195608
Name:WALMART
Entity Type:Organization
Organization Name:WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DIGHERA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:906-779-4236
Mailing Address - Street 1:1920 S STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3641
Mailing Address - Country:US
Mailing Address - Phone:906-779-7187
Mailing Address - Fax:906-779-3718
Practice Address - Street 1:1920 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3641
Practice Address - Country:US
Practice Address - Phone:906-779-7187
Practice Address - Fax:906-779-3718
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALMART PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033572251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health