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	3336C0003X	Community/Retail Pharmacy	15203	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2144419	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639593304
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	:	479-277-2500
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	125 MARYPORT DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29575-6513
Country	:	US
Telephone Number	:	843-232-0495
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF HEALTHCARE CONTRACTING
Name	:	SARAH LITTLE
Credential	:
Telephone Number	:	479-277-2500

Provider Enumeration Date	:	02/14/2014
Last Update Date	:	08/30/2023

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