Provider Demographics
NPI:1174916084
Name:WAL-MART STORES EAST LP
Entity type:Organization
Organization Name:WAL-MART STORES EAST LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR HEALTHCARE CONTRACT & ENRO
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:MAILSTOP 0445
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-277-2500
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:15726 SE HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:CROSS CITY
Practice Address - State:FL
Practice Address - Zip Code:32628-3568
Practice Address - Country:US
Practice Address - Phone:352-498-6034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLPH290843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014865600Medicaid
FL014865601 DMEMedicaid
2150862OtherPK
4355052799Medicare NSC