Healthcare Provider Details

I. General information

NPI: 1851767404
Provider Name (Legal Business Name): WAL-MART 4134
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12840 BEACH BLVD
STANTON CA
90680-4005
US

IV. Provider business mailing address

12840 BEACH BLVD
STANTON CA
90680-4005
US

V. Phone/Fax

Practice location:
  • Phone: 714-230-0153
  • Fax: 714-230-0134
Mailing address:
  • Phone: 714-230-0153
  • Fax: 714-230-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number67249
License Number StateCA

VIII. Authorized Official

Name: LANG LUONG
Title or Position: PHARMACY MANAGER
Credential:
Phone: 714-230-0153