Basic Information
| Provider Information | |||||||||
| NPI: | 1033623236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAL-MART STORES EAST LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792772500 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 BALMY BEACH DR | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327030000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074576293 | ||||||||
| FaxNumber: | 4074576298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2017 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, HEALTHCARE CONTRACTING & | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | PH31236 | FL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 024284300 | 05 | FL | MEDICAID | 024284301 DME | 05 | FL | MEDICAID | 2175190 | 01 | PK | OTHER |