Provider Demographics
NPI:1669871869
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:MICAJAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-509-2176
Mailing Address - Street 1:6690 REGENCY DR SE
Mailing Address - Street 2:NONE
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9514
Mailing Address - Country:US
Mailing Address - Phone:253-509-2176
Mailing Address - Fax:
Practice Address - Street 1:3497 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5634
Practice Address - Country:US
Practice Address - Phone:360-874-9063
Practice Address - Fax:360-874-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60031151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60031151OtherPHARMACIST LICENSE