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Provider Information for 1003833294


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WAL-MART STORES EAST LP

Other Names:  
Doing Business As: 
WALMART PHARMACY 10-1857

Organization Subpart: NO

NPI: 1003833294
Last Updated: 2017-02-20
Certification Date:

Details

NameValue
NPI1003833294
Enumeration Date2006-07-16
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: SARAH LITTLE
Title: Director of Healthcare Contracting
Phone: 4792772500
Mailing Address 702 SW 8TH ST
BENTONVILLE, AR 72716-0445
United States

Phone: | Fax:
 
Primary Practice Address 9303 MENTOR AVE
MENTOR, OH 44060-6413
United States

Phone: 440-974-3301 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDOH0899587
Other (non-Medicare)2072738PK
MEDICAIDOH899587
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 332B00000X - Durable Medical Equipment & Medical Supplies
No 333600000X - Pharmacy
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyOH020713400