Provider Demographics
NPI:1982158622
Name:WAL-MART PHARMACY
Entity type:Organization
Organization Name:WAL-MART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:803-381-3103
Mailing Address - Street 1:4875 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-8127
Mailing Address - Country:US
Mailing Address - Phone:803-323-2091
Mailing Address - Fax:
Practice Address - Street 1:4875 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-8127
Practice Address - Country:US
Practice Address - Phone:803-323-2091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC36649OtherSOUTH CAROLINA PHARMACY LICENSE