1730106063 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 1730106063 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:
1730106063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2025
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:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2635 PLEASANT HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-1471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-418-9535
Provider Business Practice Location Address Fax Number:
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:
480-277-6348

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: PHRE007770 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00642969A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2018943 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 007908400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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