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	332BC3200X	Customized Equipment (DME)
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1730611971
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	:	MAIL STOP 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-204-8550
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	4401 POOLE RD.
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-0000
Country	:	US
Telephone Number	:	479-258-6180
Fax Number	:

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

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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