Provider Demographics
NPI:1669540803
Name:WALNUT VILLAGE PHARMACY INC
Entity type:Organization
Organization Name:WALNUT VILLAGE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:B
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:949-551-4343
Mailing Address - Street 1:4840 IRVINE BLVD. STE 103
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1962
Mailing Address - Country:US
Mailing Address - Phone:949-551-4343
Mailing Address - Fax:949-551-3078
Practice Address - Street 1:4840 IRVINE BLVD. STE 103
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-1962
Practice Address - Country:US
Practice Address - Phone:949-551-4343
Practice Address - Fax:949-551-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2002056OtherPK
CAPHA508560Medicaid
4967490001Medicare NSC