1053702860 NPI number — WAL-MART STORES EAST LP

Table of content: (NPI 1053702860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053702860 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:
1053702860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2015
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:
9181 HIGHWAY 67
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70722-4919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-828-0029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINE
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF HEALTHCARE CONTRAC
Authorized Official Telephone Number:
479-204-8550

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY.007107-RC , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2150364 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2203673 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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