WAL-MART STORES EAST LP

Provider Demographics

• NPI: 1013934413
• Name: WAL-MART STORES EAST LP
• Entity Type: Organization
• Organization Name: WAL-MART STORES EAST LP
• Other - Org Name: WALMART PHARMACY 10-5315
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: DIRECTOR OF HEALTHCARE CONTRACTING
• Authorized Official - First Name: MATT
• Authorized Official - Last Name: MCMULLIN
• Authorized Official - Phone: 479-371-8711
• Mailing Address - Street 1: 702 SW 8TH ST
• Mailing Address - City: BENTONVILLE
• Mailing Address - State: AR
• Mailing Address - Zip Code: 72716-0445
• Mailing Address - Country: US
• Practice Address - Street 1: 2354 COMMERCE PARK DR STE 100
• Practice Address - City: ORLANDO
• Practice Address - State: FL
• Practice Address - Zip Code: 32819-8601
• Practice Address - Country: US
• Practice Address - Phone: 877-453-4566
• Practice Address - Fax: 866-537-0877
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-07-16
• Last Update Date: 2023-11-13

Provider Licenses

State	License ID	Taxonomies
ND	965	3336S0011X
MT	PHA-MOP-LIC-12447	3336S0011X
MN	262265	3336S0011X
KY	FL873	3336S0011X
IL	054.015021	3336S0011X
AR	OS01543	3336S0011X
IN	64000468A	3336S0011X
LA	PHY.005063-OS	3336S0011X
TX	22601	3336S0011X
TN	3872	3336S0011X
MI	5301007714	3336S0011X
MO	2003010214	3336S0011X
OK	99-6096	3336S0011X
FL	PH18943	3336S0011X
OH	021368750-03	3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
PA	1007455310380	Medicaid
AL	1013934413	Medicaid
FL	025831800	Medicaid
FL	25831800	Medicaid
FL	006340	Medicaid
	2015188	Other	PK
FL	3810010863	Medicaid
FL	100505069	Medicaid
NJ	0311413	Medicaid
FL	100445350C	Medicaid
CO	80658873	Medicaid
FL	1013934413	Medicaid
	4355051904	Medicare NSC