Basic Information
| Provider Information | |||||||||
| NPI: | 1710407895 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALMART INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALMART PHARMACY 10-2483 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792582115 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 6973 BLUE DIAMOND RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891789213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024083596 | ||||||||
| FaxNumber: | 7024083597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAUVER | ||||||||
| AuthorizedOfficialFirstName: | DEB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SPECIALIST PLAN ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4792582115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PH03796 | NV | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1710407895 | 05 | NV | MEDICAID | 2170422 | 01 | PK | OTHER |