Healthcare Provider Details

I. General information

NPI: 1932217866
Provider Name (Legal Business Name): WALTON DRUG CO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MKL JR BLVD SUITE A
MONROE GA
30655
US

IV. Provider business mailing address

PO BOX 965
MONROE GA
30655-0965
US

V. Phone/Fax

Practice location:
  • Phone: 770-267-2559
  • Fax: 770-267-6138
Mailing address:
  • Phone: 770-267-2559
  • Fax: 770-267-6138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE004488
License Number StateGA

VIII. Authorized Official

Name: WANDA HICKMAN
Title or Position: OWNER, AO
Credential:
Phone: 770-267-2559