MEDICARE: WAL-MART STORES TEXAS LLC

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	21674	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2100390	OTHER		PK

General Provider Information

NPI Number	:	1447277611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES TEXAS LLC

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-1238
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	1311 S JACKSON ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-3050
Country	:	US
Telephone Number	:	903-586-1164
Fax Number	:

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

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	12/01/2023

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