Provider Demographics
NPI:1699211300
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:AMBER
Authorized Official - Middle Name:HAISLIP
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-535-1170
Mailing Address - Street 1:251 PREMIER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-5076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 PREMIER BLVD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-5076
Practice Address - Country:US
Practice Address - Phone:252-535-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC243063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy