Healthcare Provider Details

I. General information

NPI: 1740657618
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 TOBEY RD
WAREHAM MA
02571-1083
US

IV. Provider business mailing address

702 SW 8TH ST MAILSTOP 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 508-295-8855
  • Fax: 508-295-6742
Mailing address:
  • Phone: 479-258-6180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LAURA LEVINE
Title or Position: DIR HEALTHCARE CONTRACTING & ENROLL
Credential:
Phone: 479-204-8550