Provider Demographics
NPI:1245777895
Name:WAL-MART STORES TEXAS LLC
Entity Type:Organization
Organization Name:WAL-MART STORES TEXAS LLC
Other - Org Name:WALMART PHARMACY 10-6467
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. HEALTHCARE CONTRACT & ENROLLME
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:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-204-1258
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:450 S SOUTHEAST LOOP 323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8646
Practice Address - Country:US
Practice Address - Phone:903-405-6389
Practice Address - Fax:903-405-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX471170Medicaid
2167668OtherPK