Provider Demographics
NPI:1750785127
Name:WALMART PHARMACY
Entity type:Organization
Organization Name:WALMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-231-6071
Mailing Address - Street 1:3812 LIBERTY HWY
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621
Mailing Address - Country:US
Mailing Address - Phone:864-231-6071
Mailing Address - Fax:864-231-6073
Practice Address - Street 1:3812 LIBERTY HWY
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1344
Practice Address - Country:US
Practice Address - Phone:864-231-6071
Practice Address - Fax:864-231-6073
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALMART
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC05847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1234567Medicaid