Healthcare Provider Details

I. General information

NPI: 1104063635
Provider Name (Legal Business Name): WALMART INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 09/19/2025
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4689 W CEDAR HILLS DR
CEDAR HILLS UT
84062-8093
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-5067
  • Fax:
Mailing address:
  • Phone: 479-277-1238
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7218631-1703
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1104063635
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 2
Identifier2118803
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

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