Provider Demographics
NPI:1841219821
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: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:
Mailing Address - Fax:
Practice Address - Street 1:3501 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3104
Practice Address - Country:US
Practice Address - Phone:941-727-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-19
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FLPH164223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106590400Medicaid
1084918OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4355050992Medicare NSC