1013934413 NPI number — WAL-MART STORES EAST LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013934413 NPI number — WAL-MART STORES EAST LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAL-MART STORES EAST LP
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:
Provider Other Organization Name Type Code:
6
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:
1013934413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2025
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:
479-277-1242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2354 COMMERCE PARK DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32819-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-453-4566
Provider Business Practice Location Address Fax Number:
866-537-0877
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANONIC
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR DIRECTOR, ENROLLMENT
Authorized Official Telephone Number:
479-371-1168

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X , with the licence number:  965 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHA-MOP-LIC-12447 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 262265 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: FL873 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 054.015021 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 64000468A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHY.005063-OS , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 22601 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 3872 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 5301007714 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 2003010214 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 99-6096 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PH18943 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 021368750-03 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: OS01543 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006340 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 025831800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0311413 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013934413 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25831800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80658873 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2015188 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3810010863 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013934413 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007455310380 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100445350C , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100505069 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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