Provider Demographics
NPI:1376560557
Name:WAL-MART STORES EAST LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:WAL MART PHARMACIES 10-1725
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NEW STORE SYS ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:179-273-4885
Mailing Address - Street 1:MAILSTOP 0445
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-6209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5331 SALEM AVE
Practice Address - Street 2:WAL MART PHARMACIES 10-1725
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-1625
Practice Address - Country:US
Practice Address - Phone:937-837-5240
Practice Address - Fax:937-854-3078
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALMART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-16
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
OH2680500333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH849934Medicaid
3655923OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4355051512Medicare NSC