Provider Demographics
NPI:1639796022
Name:WALL DRUGS OF PAMPLICO, INC.
Entity Type:Organization
Organization Name:WALL DRUGS OF PAMPLICO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-386-6135
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-0240
Mailing Address - Country:US
Mailing Address - Phone:843-905-0200
Mailing Address - Fax:843-905-0201
Practice Address - Street 1:616 S. WALNUT STREET
Practice Address - Street 2:
Practice Address - City:PAMPLICO
Practice Address - State:SC
Practice Address - Zip Code:29583
Practice Address - Country:US
Practice Address - Phone:843-933-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy