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Provider Information for 1669499976


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WAL-MART STORES EAST LP

Other Names:  
Doing Business As: 
WAL-MART PHARMACY 10-1378

Organization Subpart: NO

NPI: 1669499976
Last Updated: 2023-08-30
Certification Date: 2023-08-30

Details

NameValue
NPI1669499976
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 2304 LINCOLNWAY E
GOSHEN, IN 46526-6421
United States

Phone: 574-534-4483 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
CONNECT URL
https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service
2.16.840.1.113883.3.667.2
CMS esMD eMDR Ability Network 100 N 6th St Ste 900A
Minneapolis, MN 55403-1516
United States
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDIN100295550
MEDICAIDIN100295550A
Other (non-Medicare)2026957PK
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 332B00000X - Durable Medical Equipment & Medical Supplies
No 333600000X - Pharmacy
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyIN60005055A