Provider Demographics
NPI:1871510123
Name:WAL-MART STORES EAST LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:WALMART PHARMACY 10-0088
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
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:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-2438
Practice Address - Country:US
Practice Address - Phone:417-926-4129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MO20020095173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050746OtherPK
MO602241903Medicaid
MO602241903Medicaid