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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	P03008	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2037529	OTHER		PK

General Provider Information

NPI Number	:	1467479741
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	:	2701 PORT COVINGTON DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21230-5004
Country	:	US
Telephone Number	:	410-837-8924
Fax Number	:

Authorized Official
Title or Position	:	MGR OF GOVERNMENT CONTRACTING
Name	:	LAURA LEVINE
Credential	:
Telephone Number	:	479-204-8550

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	07/12/2013

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