Provider Demographics
NPI:1649671777
Name:WALMART
Entity type:Organization
Organization Name:WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:CALEDONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:931-607-1979
Mailing Address - Street 1:3251 CERRILLOS RD
Mailing Address - Street 2:PHARMACY
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2924
Mailing Address - Country:US
Mailing Address - Phone:505-473-4261
Mailing Address - Fax:505-474-0412
Practice Address - Street 1:3251 CERRILLOS RD
Practice Address - Street 2:PHARMACY
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2924
Practice Address - Country:US
Practice Address - Phone:505-473-4261
Practice Address - Fax:505-474-0412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy