Basic Information
Provider Information
NPI: 1184095325
EntityType: 2
ReplacementNPI:  
OrganizationName: WAL-MART NEIGHBORHOOD MARKET
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 973 N HARRISON AVE
Address2:  
City: CARY
State: NC
PostalCode: 275133904
CountryCode: US
TelephoneNumber: 9193379784
FaxNumber: 9193379785
Practice Location
Address1: 973 N HARRISON AVE
Address2:  
City: CARY
State: NC
PostalCode: 275133904
CountryCode: US
TelephoneNumber: 9193379784
FaxNumber: 9193379785
Other Information
ProviderEnumerationDate: 10/14/2015
LastUpdateDate: 10/14/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LE
AuthorizedOfficialFirstName: LAN
AuthorizedOfficialMiddleName: T
AuthorizedOfficialTitleorPosition: STAFF PHARMACIST
AuthorizedOfficialTelephone: 9193379784
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PHARM.D., MBA
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X23411NCY193400000X SINGLE SPECIALTY GROUPPharmacy Service ProvidersPharmacist 

No ID Information.


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