Basic Information
Provider Information | |||||||||
NPI: | 1609325455 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALMART | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1133 N GRAPE DR | ||||||||
Address2: | APT B105 | ||||||||
City: | MOSES LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 988374052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4133867533 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1399 NAT WASHINGTON WAY | ||||||||
Address2: |   | ||||||||
City: | EPHRATA | ||||||||
State: | WA | ||||||||
PostalCode: | 988232629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097548847 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2016 | ||||||||
LastUpdateDate: | 09/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHAU | ||||||||
AuthorizedOfficialFirstName: | FIONNA | ||||||||
AuthorizedOfficialMiddleName: | CHIN | ||||||||
AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
AuthorizedOfficialTelephone: | 4133867533 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PH60665016 | WA | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.