Provider Demographics
NPI:1285789024
Name:WALLYS PHARMACY INC
Entity type:Organization
Organization Name:WALLYS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-799-9089
Mailing Address - Street 1:933 OLD ROCKFORD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-5356
Mailing Address - Country:US
Mailing Address - Phone:336-789-9089
Mailing Address - Fax:336-789-1161
Practice Address - Street 1:933 OLD ROCKFORD ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5356
Practice Address - Country:US
Practice Address - Phone:336-789-9089
Practice Address - Fax:336-789-1161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0865469Medicaid
NC0865469Medicaid