Basic Information
| Provider Information | |||||||||
| NPI: | 1710489406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALMART INC | ||||||||
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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: | 1791 ENSIGN LANE SE | ||||||||
| Address2: | |||||||||
| City: | WARRENTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971467339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038610644 | ||||||||
| FaxNumber: | 5038610897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR 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 | RP-0003387 | OR | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2103875 | 05 | WA | MEDICAID | 2176573 | 01 | PK | OTHER | 500745490 | 05 | OR | MEDICAID |