Provider Demographics
NPI:1619304425
Name:WAL-MART STORES TEXAS LLC
Entity Type:Organization
Organization Name:WAL-MART STORES TEXAS LLC
Other - Org Name:WALMART PHARMACY 10-0999
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTHCARE CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-371-8711
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6209
Mailing Address - Country:US
Mailing Address - Phone:479-204-8550
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:7239 SW LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78242-2049
Practice Address - Country:US
Practice Address - Phone:210-247-5912
Practice Address - Fax:210-247-5906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX289173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470176Medicaid
2142708OtherPK
2142708OtherPK