Healthcare Provider Details

I. General information

NPI: 1629274063
Provider Name (Legal Business Name): WALL DRUGS OF JOHNSONVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 EAST STUCKEY STREET
JOHNSONVILLE SC
29555-0545
US

IV. Provider business mailing address

239 EAST STUCKEY STR.
JOHNSONVILLE SC
29555-0545
US

V. Phone/Fax

Practice location:
  • Phone: 843-380-1066
  • Fax:
Mailing address:
  • Phone: 843-380-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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