Basic Information
| Provider Information | |||||||||
| NPI: | 1437606167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALMART | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1399 NAT WASHINGTON WAY | ||||||||
| Address2: | |||||||||
| City: | EPHRATA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988232629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097548847 | ||||||||
| FaxNumber: | 5097548850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 PITCHER CANYON RD | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988019446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092644994 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2016 | ||||||||
| LastUpdateDate: | 09/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | FISCHER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5092644994 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH-00015989 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | PH 00015989 | 01 | WA | WASHINGTON STATE DEPARTMENT OF HEALTH/PHARMACIST LICENSE | OTHER |