Basic Information
| Provider Information | |||||||||
| NPI: | 1487058129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES EAST LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALMART PHARMACY 10-3756 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 124 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OKEMAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748592801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186239207 | ||||||||
| FaxNumber: | 9186239221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DR. HEALTHCARE & ENROLLMENT | ||||||||
| 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 | 51-6875 | OK | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2149232 | 01 | PK | OTHER | 100816310F | 05 | OK | MEDICAID |