Healthcare Provider Details

I. General information

NPI: 1689918468
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 MARTIN LUTHER KING JR DR NW
ATLANTA GA
30314-3644
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 404-460-2706
  • Fax:
Mailing address:
  • Phone: 479-204-0709
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009887
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SARAH LITTLE
Title or Position: DIRECTOR OF HEALTHCARE CONTRACTING
Credential:
Phone: 479-277-2500