Provider Demographics
NPI:1699143453
Name:WAL-MART
Entity type:Organization
Organization Name:WAL-MART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ALONNA
Authorized Official - Last Name:CLUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:501-328-3606
Mailing Address - Street 1:3009 E CAUSEWAY APPROACH
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3510
Mailing Address - Country:US
Mailing Address - Phone:985-626-1118
Mailing Address - Fax:
Practice Address - Street 1:3009 E CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3510
Practice Address - Country:US
Practice Address - Phone:985-626-1118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.0211363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy