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Provider Information for 1922025139


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WAL-MART STORES EAST LP

Other Names:  
Doing Business As: 
WAL-MART PHARMACY 10-1639

Organization Subpart: NO

NPI: 1922025139
Last Updated: 2017-02-28
Certification Date:

Details

NameValue
NPI1922025139
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 2395 MAIN ST
ROCHESTER, IN 46975-9137
United States

Phone: 574-223-9482 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDIN100118510A
Other (non-Medicare)2027141PK
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 332B00000X - Durable Medical Equipment & Medical Supplies
No 333600000X - Pharmacy
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyIN60005073A