Provider Demographics
NPI:1104002534
Name:WAL-MART STORES, INC.
Entity Type:Organization
Organization Name:WAL-MART STORES, INC.
Other - Org Name:WAL-MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TP ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-1238
Mailing Address - Street 1:MAIL STOP 0445
Mailing Address - Street 2:702 SW 8TH ST
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:912 11TH STREET EAST
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318
Practice Address - Country:US
Practice Address - Phone:701-228-5930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-16
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3504481OtherNCPDP PROVIDER IDENTIFICATION NUMBER