Basic Information
Provider Information
NPI: 1760933196
EntityType: 2
ReplacementNPI:  
OrganizationName: WAL-MART STORES EAST, LP
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: WALMART PHARMACY 10-5367
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 702 SW 8TH ST
Address2: MAIL STOP 0445
City: BENTONVILLE
State: AR
PostalCode: 727160445
CountryCode: US
TelephoneNumber: 4792586180
FaxNumber: 4792774331
Practice Location
Address1: 1705 S KINGS HWY
Address2:  
City: MYRTLE BEACH
State: SC
PostalCode: 295774601
CountryCode: US
TelephoneNumber: 8433535640
FaxNumber: 8433535639
Other Information
ProviderEnumerationDate: 10/20/2016
LastUpdateDate: 03/17/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LEVINE
AuthorizedOfficialFirstName: LAURA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: DIR HEALTHCARE CONTRACT & EQUIPMENT
AuthorizedOfficialTelephone: 4792048550
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X  N SuppliersDurable Medical Equipment & Medical Supplies 
3336C0003X  N SuppliersPharmacyCommunity/Retail Pharmacy
333600000X17143SCY SuppliersPharmacy 

ID Information
IDTypeStateIssuerDescription
216750901 PKOTHER


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