1790703122 NPI number — WAL-MART STORES EAST LP

Table of content: (NPI 1790703122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790703122 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:
1790703122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2025
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:
9205 GIBSONTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GIBSONTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33534-4608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-672-4932
Provider Business Practice Location Address Fax Number:
479-277-4331
Provider Enumeration Date:
07/17/2006

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:
480-853-0515

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH21888 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2006414 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 031366100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH21888 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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