Healthcare Provider Details

I. General information

NPI: 1932200912
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 LA HIGHWAY 1 S
PORT ALLEN LA
70767-5858
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-6209
US

V. Phone/Fax

Practice location:
  • Phone: 225-749-7454
  • Fax: 225-749-7418
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number4788RC
License Number StateLA

VIII. Authorized Official

Name: RANDY WRIGHT
Title or Position: PHY ENROLLMENT SPECIALIST
Credential:
Phone: 479-273-6574