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General NPI Number Information
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NPI Number | 1447650254
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Entity Type | Organization
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Legal Business Name | WAL-MART
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Dates
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Enumeration Date | 08/28/2014
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Last Update Date | 08/28/2014
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Provider Practice Location Address
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Address Line | 26502 TOWNE CENTRE DR
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City | FOOTHILL RANCH
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State | CA
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Zip | 92610-3448
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Country | US
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Telephone | 949-837-0504
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Fax |
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Provider Business Mailing Address
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Address Line | 22612 MOJAVE LN
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City | MISSION VIEJO
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State | CA
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Zip | 92691-1519
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Country | US
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Telephone | 818-256-9887
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Fax |
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | HALA GOURGY
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Credential | RPH
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Telephone | 949-837-0504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY408530
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License Number State | CA
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