Provider Demographics
NPI:1609818673
Name:WAL-MART STORES EAST LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:WALMART PHARMACY 10-3309
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:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4250 PHILIPS HWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-6730
Practice Address - Country:US
Practice Address - Phone:904-737-7001
Practice Address - Fax:479-277-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336S0011X
FLPH220423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2006721OtherPK
FL031565600Medicaid
4355052132Medicare NSC