Provider Demographics
NPI:1972844405
Name:WAL-MART STORES INC
Entity Type:Organization
Organization Name:WAL-MART STORES INC
Other - Org Name:WAL-MART PHARMACY 10-3086
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR H&W BILLING, RECON
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BADEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-2611
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:479-204-8741
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:701 W CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2104
Practice Address - Country:US
Practice Address - Phone:213-337-0182
Practice Address - Fax:213-337-0174
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-07
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 512153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139318OtherPK
0279613502Medicare NSC