MEDICARE: WAL-MART STORES EAST LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336S0011X	Specialty Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336C0003X	Community/Retail Pharmacy	0201003677	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2104695	OTHER	PK

General Provider Information

NPI Number	:	1376560482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST LP

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2410 SHEILA LN
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-2041
Country	:	US
Telephone Number	:	804-320-0099
Fax Number	:	804-320-0099

Authorized Official
Title or Position	:	DIRECTOR OF HEALTHCARE CONTRACTING
Name	:	MATT MCMULLIN
Credential	:
Telephone Number	:	479-371-8711

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	06/25/2024

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Directions to “WAL-MART STORES EAST LP ” Practice Location

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