Healthcare Provider Details

I. General information

NPI: 1376560557
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 SALEM AVE WAL MART PHARMACIES 10-1725
TROTWOOD OH
45426-1625
US

IV. Provider business mailing address

MAILSTOP 0445
BENTONVILLE AR
72716-6209
US

V. Phone/Fax

Practice location:
  • Phone: 937-837-5240
  • Fax: 937-854-3078
Mailing address:
  • Phone:
  • 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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2680500
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT CHOAT
Title or Position: NEW STORE SYS ENROLLMENT
Credential:
Phone: 179-273-4885