Provider Demographics
NPI:1912381799
Name:WALMART
Entity Type:Organization
Organization Name:WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHELSEY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:MOZINGO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:843-424-6929
Mailing Address - Street 1:2219 BREWSTER DR UNIT 326
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1746
Mailing Address - Country:US
Mailing Address - Phone:843-424-6929
Mailing Address - Fax:
Practice Address - Street 1:1310 N FRASER ST
Practice Address - Street 2:ATTN: PHARMACY
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2800
Practice Address - Country:US
Practice Address - Phone:843-527-2223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-12
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC361013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy