=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396195608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALMART
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 06/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1920 S STEPHENSON AVE
-----------------------------------------------------
City | IRON MOUNTAIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49801-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-779-7187
-----------------------------------------------------
Fax | 906-779-3718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1920 S STEPHENSON AVE
-----------------------------------------------------
City | IRON MOUNTAIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49801-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-779-7187
-----------------------------------------------------
Fax | 906-779-3718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | LEIGH ANN DIGHERA
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 906-779-4236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 5302033572
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------