Provider Demographics
NPI:1639598931
Name:WAL MART
Entity Type:Organization
Organization Name:WAL MART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:PANDYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-834-7179
Mailing Address - Street 1:9 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS RST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-2168
Mailing Address - Country:US
Mailing Address - Phone:864-834-7179
Mailing Address - Fax:
Practice Address - Street 1:9 BENTON RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS RST
Practice Address - State:SC
Practice Address - Zip Code:29690-2168
Practice Address - Country:US
Practice Address - Phone:864-834-7179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4637261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service