Provider Demographics
NPI:1801208426
Name:WAL-MART STORES TEXAS, LLC
Entity Type:Organization
Organization Name:WAL-MART STORES TEXAS, LLC
Other - Org Name:WALMART CARE CLINIC 10-4509
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF HEALTHCARE CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-8550
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:479-204-8550
Mailing Address - Fax:
Practice Address - Street 1:8840 BENBROOK BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-3440
Practice Address - Country:US
Practice Address - Phone:682-233-6832
Practice Address - Fax:817-249-7375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-02
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358654ZHTPOtherMEDICARE PTAN