Provider Demographics
NPI:1881064335
Name:WAL MART
Entity type:Organization
Organization Name:WAL MART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CONSTANTINE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MAKHULI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:919-852-0749
Mailing Address - Street 1:2010 KILDAIRE FARM RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-6614
Mailing Address - Country:US
Mailing Address - Phone:919-852-0749
Mailing Address - Fax:
Practice Address - Street 1:2010 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6614
Practice Address - Country:US
Practice Address - Phone:919-852-0749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty