Basic Information
| Provider Information | |||||||||
| NPI: | 1598166001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALMART | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 SE EVERETT MALL WAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982082838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893364 | ||||||||
| FaxNumber: | 4257893365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 SE EVERETT MALL WAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982082838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893364 | ||||||||
| FaxNumber: | 4257893365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 09/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | MUHAT | ||||||||
| AuthorizedOfficialFirstName: | MERIVIC | ||||||||
| AuthorizedOfficialMiddleName: | DELIGERO | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4252385136 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH00040674 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 2038070 | 05 | WA | MEDICAID | FW4794207 | 01 | WA | DEA | OTHER | 4936235 | 01 | WA | NCPDP | OTHER |