Provider Demographics
NPI:1568714137
Name:WAL-MART STORES EAST LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:WAL-MART PHARMACY 10-2500
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-1238
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:479-277-1238
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:945 MONROE ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NC
Practice Address - Zip Code:28327-9339
Practice Address - Country:US
Practice Address - Phone:910-947-6682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-08
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC113413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568714137Medicaid
2137308OtherPK
4355052568Medicare NSC