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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 23411 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |   |
No ID Information.