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General NPI Number Information
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NPI Number | 1629480298
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Entity Type | Organization
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Legal Business Name | WALMART PHARMACY #1070
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 05/29/2014
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Provider Practice Location Address
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Address Line | 88 HIGHLAND XING
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City | EAST ELLIJAY
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State | GA
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Zip | 30540-6052
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Country | US
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Telephone | 706-276-1180
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Fax |
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Provider Business Mailing Address
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Address Line | 405 RIVEREDGE LN # 9061
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City | ELLIJAY
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State | GA
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Zip | 30540-5390
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Country | US
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Telephone | 706-502-2374
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Fax |
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Authorized Official
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Title or Position | STAFF PHARMACIST
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Name | ROBYN CARTER
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Credential | RPH
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Telephone | 706-502-2374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number | 12398
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License Number State | GA
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