Healthcare Provider Details

I. General information

NPI: 1548719040
Provider Name (Legal Business Name): WALMART PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2016
Last Update Date: 09/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SAN MATEO BLVD SE
ALBUQUERQUE NM
87108-5629
US

IV. Provider business mailing address

2428 WINDWARD DR NW
ALBUQUERQUE NM
87120-3698
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-1915
  • Fax: 505-268-0059
Mailing address:
  • Phone: 505-506-8660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License NumberRP00008596
License Number StateNM

VIII. Authorized Official

Name: MORTEZA PARHIZKAR
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 505-506-8660