Provider Demographics
NPI:1932217866
Name:WALTON DRUG CO INC
Entity Type:Organization
Organization Name:WALTON DRUG CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-267-2559
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-0965
Mailing Address - Country:US
Mailing Address - Phone:770-267-2559
Mailing Address - Fax:770-267-6138
Practice Address - Street 1:150 MKL JR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655
Practice Address - Country:US
Practice Address - Phone:770-267-2559
Practice Address - Fax:770-267-6138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 333600000X
GAPHRE0044883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00329667AMedicaid
2012680OtherPK
GA00329667AMedicaid