Healthcare Provider Details

I. General information

NPI: 1245321363
Provider Name (Legal Business Name): WALL DRUGS OF JOHNSONVILLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 STUCKEY STREET
JOHNSONVILLE SC
29555
US

IV. Provider business mailing address

239 STUCKEY ST
JOHNSONVILLE SC
29555-6448
US

V. Phone/Fax

Practice location:
  • Phone: 843-386-6135
  • Fax: 843-380-1025
Mailing address:
  • Phone: 843-386-6135
  • Fax: 843-380-1025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number50006733
License Number StateSC

VIII. Authorized Official

Name: MR. DERRICK ALLAN WALL
Title or Position: OWNER RPH
Credential: RPH
Phone: 843-386-6135