Basic Information
| Provider Information | |||||||||
| NPI: | 1982645495 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALMART | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2399 N POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | DUNDALK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212221623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102840126 | ||||||||
| FaxNumber: | 4102840292 | ||||||||
| Practice Location | |||||||||
| Address1: | 2399 N POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | DUNDALK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212221623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102840126 | ||||||||
| FaxNumber: | 4102840292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANCE | ||||||||
| AuthorizedOfficialFirstName: | LONI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST/MANAGERX | ||||||||
| AuthorizedOfficialTelephone: | 4102840126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | BW6291001 | MD | Y | Suppliers | Pharmacy |
No ID Information.