Healthcare Provider Details

I. General information

NPI: 1447650254
Provider Name (Legal Business Name): WAL-MART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26502 TOWNE CENTRE DR
FOOTHILL RANCH CA
92610-3448
US

IV. Provider business mailing address

22612 MOJAVE LN
MISSION VIEJO CA
92691-1519
US

V. Phone/Fax

Practice location:
  • Phone: 949-837-0504
  • Fax:
Mailing address:
  • Phone: 818-256-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY408530
License Number StateCA

VIII. Authorized Official

Name: HALA GOURGY
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 949-837-0504