Provider Demographics
NPI:1104364157
Name:WALMART INC.
Entity Type:Organization
Organization Name:WALMART INC.
Other - Org Name:WALMART PHARMACY 10-5725
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPECIALIST PLAN ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-258-2115
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-258-2115
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:831 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2109
Practice Address - Country:US
Practice Address - Phone:520-719-6340
Practice Address - Fax:520-719-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
AZY0071503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ261778Medicaid
2168023OtherPK