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	3336C0003X	Community/Retail Pharmacy	2012034758	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2136760	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508115726
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	:	72716-6209
Country	:	US
Telephone Number	:	479-277-1238
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	3536 W MOUNT VERNON ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-5207
Country	:	US
Telephone Number	:	417-616-2674
Fax Number	:

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

Provider Enumeration Date	:	09/04/2012
Last Update Date	:	05/30/2024

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