1821015090 NPI number — WAL-MART STORES TEXAS LLC

Table of content: (NPI 1821015090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821015090 NPI number — WAL-MART STORES TEXAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAL-MART STORES TEXAS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WALMART PHARMACY 10-0163
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821015090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 SW 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72716-0445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-277-1238
Provider Business Mailing Address Fax Number:
479-277-4331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4810 NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75965-1876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-564-1158
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCMULLIN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR CONTRACTING
Authorized Official Telephone Number:
479-371-8711

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 21672 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2100956 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 469191 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".