MEDICARE: WALMART INC.

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	3336S0011X	Specialty Pharmacy
4	3336C0003X	Community/Retail Pharmacy	PH03796	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2170422	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710407895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALMART INC.

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-258-2115
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	6973 BLUE DIAMOND RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-9213
Country	:	US
Telephone Number	:	702-408-3596
Fax Number	:	702-408-3597

Authorized Official
Title or Position	:	SPECIALIST PLAN ENROLLMENT
Name	:	DEB LAUVER
Credential	:
Telephone Number	:	479-258-2115

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	08/29/2023

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Directions to “WALMART INC. ” Practice Location

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