Basic Information
| Provider Information | |||||||||
| NPI: | 1174939326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES EAST LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WALMART PHARMACY 10-2173 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | MAILSTOP 0445 | ||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792772500 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 14331 COUNTY RD 99 | ||||||||
| Address2: | |||||||||
| City: | HEADLAND | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346939013 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR HEALTHCARE CONTRACT & ENRO | ||||||||
| AuthorizedOfficialTelephone: | 4792048550 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 114410 | AL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 167520 | 05 | AL | MEDICAID | 2146781 | 01 | PK | OTHER |