Provider Demographics
NPI:1629390968
Name:WALMART PHARMACY
Entity Type:Organization
Organization Name:WALMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:607-431-9832
Mailing Address - Street 1:143 PLEASANT MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-5039
Mailing Address - Country:US
Mailing Address - Phone:607-547-7115
Mailing Address - Fax:607-431-9206
Practice Address - Street 1:143 PLEASANT MEADOWS RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-5039
Practice Address - Country:US
Practice Address - Phone:607-547-7115
Practice Address - Fax:607-431-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027503333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy