Provider Demographics
NPI:1861860470
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:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KERR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:708-926-4743
Mailing Address - Street 1:505 RIVERSTONE PKWY
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-7207
Mailing Address - Country:US
Mailing Address - Phone:708-926-4743
Mailing Address - Fax:
Practice Address - Street 1:505 RIVERSTONE PKWY
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-7207
Practice Address - Country:US
Practice Address - Phone:708-926-4743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.2987613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy