Healthcare Provider Details

I. General information

NPI: 1770982001
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E LEE ST
SARDIS MS
38666-1236
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-9001
  • Fax: 662-487-9003
Mailing address:
  • Phone: 479-204-8705
  • Fax: 479-277-4331

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 Number13604/ 1.2
License Number StateMS

VIII. Authorized Official

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