Basic Information
| Provider Information | |||||||||
| NPI: | 1912924291 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES EAST LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WALMART PHARMACY 10-2551 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792779170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 209 E RIDGEVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217715257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018294403 | ||||||||
| FaxNumber: | 3018294425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTHCARE CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
| 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 | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | P02592 | MD | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 417002400 | 05 | MD | MEDICAID | 2037169 | 01 | PK | OTHER |