Provider Demographics
NPI:1952710493
Name:WAL-MART STORES EAST , LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST , LP
Other - Org Name:WALMART PHARMACY 10-6166
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:479-277-1242
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:10290 DIBERVILLE BLVD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2536
Practice Address - Country:US
Practice Address - Phone:228-271-6753
Practice Address - Fax:228-271-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MS13428/ 1.23336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147300OtherPK
MS02879529Medicaid
4355052673Medicare NSC