=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235532045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAL-MART STORES EAST , LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1840 MCKEEN PL
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-4465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-267-3617
-----------------------------------------------------
Fax | 318-267-3618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SW 8TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72716-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-204-8550
-----------------------------------------------------
Fax | 479-277-4331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MATTHEW MCMULLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-371-8711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY.007035-RC
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------