Provider Demographics
NPI:1679914261
Name:WALMART
Entity Type:Organization
Organization Name:WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:ALTMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:479-586-3101
Mailing Address - Street 1:9600 PARKSOUTH CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 PARKSOUTH CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6424
Practice Address - Country:US
Practice Address - Phone:479-586-3101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 50266251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS 50266OtherFLORIDA PHARMACIST LICENSE