MEDICARE: WAL-MART STORES EAST , LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336S0011X	Specialty Pharmacy
4	3336C0003X	Community/Retail Pharmacy	0201003417	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2107235	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083631188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST , LP

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2021 LYNNHAVEN PKWY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-1410
Country	:	US
Telephone Number	:	757-416-3490
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MATTHEW MCMULLIN
Credential	:
Telephone Number	:	479-371-8711

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	05/15/2024

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