Provider Demographics
NPI:1982927406
Name:WALLS LTC PHARMACY INC
Entity Type:Organization
Organization Name:WALLS LTC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-738-0804
Mailing Address - Street 1:1020 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4321
Mailing Address - Country:US
Mailing Address - Phone:701-738-0804
Mailing Address - Fax:701-738-0806
Practice Address - Street 1:1322 8TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-738-0804
Practice Address - Fax:701-738-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9613336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263545OtherMINNESOTA STATE LISC
ND961OtherSTATE PHARMACY LISCENCE
ND1456006Medicaid
MN198282746Medicaid
MN263545OtherMINNESOTA STATE LISC