Provider Demographics
NPI:1851848832
Name:WALMART 3183
Entity type:Organization
Organization Name:WALMART 3183
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:P
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:305-910-2558
Mailing Address - Street 1:1499 S DIXIE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030
Mailing Address - Country:US
Mailing Address - Phone:305-910-2558
Mailing Address - Fax:305-910-2530
Practice Address - Street 1:14030 SW 74TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-3131
Practice Address - Country:US
Practice Address - Phone:305-910-2558
Practice Address - Fax:305-910-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty