Provider Demographics
NPI:1871989087
Name:WALMART
Entity type:Organization
Organization Name:WALMART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-330-6147
Mailing Address - Street 1:4215 N DRINKWATER BLVD
Mailing Address - Street 2:APT. 305
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3930
Mailing Address - Country:US
Mailing Address - Phone:941-330-6147
Mailing Address - Fax:
Practice Address - Street 1:800 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5225
Practice Address - Country:US
Practice Address - Phone:480-966-2791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS021138261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health