Provider Demographics
NPI:1952704751
Name:WAL-MART STORES EAST , LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST , LP
Other - Org Name:WALMART PHARMACY 10-3637
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
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:479-258-2115
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:1001 E MAIN ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2137
Practice Address - Country:US
Practice Address - Phone:405-577-0051
Practice Address - Fax:405-577-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
OK26-69213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149141OtherPK
OK100242350 CMedicaid
4355052729Medicare NSC