Provider Demographics
NPI:1376560698
Name:WAL-MART STORES EAST LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:WAL-MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHY ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-273-6574
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-6209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4840 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3302
Practice Address - Country:US
Practice Address - Phone:502-968-8776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO21163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1819222OtherOTHER ID NUMBER
KY5402301500Medicaid
1819222OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KY5400733100Medicaid
4355051130Medicare NSC