Provider Demographics
NPI:1194197533
Name:WAL-MART STORES EAST LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:WALMART PHARMACY 10-5135
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTHCARE CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-2500
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:MAILSTOP 0445
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-6209
Mailing Address - Country:US
Mailing Address - Phone:479-204-8550
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:102 GATEWAY CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-9204
Practice Address - Country:US
Practice Address - Phone:270-351-3625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
KYP07721333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155373OtherPK
KY7100399060Medicaid
2155373OtherPK