Provider Demographics
NPI:1134560451
Name:WAL-MART STORES INC
Entity type:Organization
Organization Name:WAL-MART STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR OF GOV. 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:479-204-8741
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:2253 S MONACO PKWY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5813
Practice Address - Country:US
Practice Address - Phone:303-323-4416
Practice Address - Fax:303-323-4410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-15
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
COPDO.16800000383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141214OtherPK
2141214OtherPK