Provider Demographics
NPI:1952857856
Name:WAL-MART
Entity Type:Organization
Organization Name:WAL-MART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY CLINICAL SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:801-721-9246
Mailing Address - Street 1:PO BOX 1041
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-1041
Mailing Address - Country:US
Mailing Address - Phone:801-721-9246
Mailing Address - Fax:
Practice Address - Street 1:1710 E SKYLINE DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5202
Practice Address - Country:US
Practice Address - Phone:801-479-6895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7622261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center