1114082997 NPI number — WAL-MART STORES EAST, LP

Table of content: (NPI 1114082997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114082997 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:
1114082997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
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:
72716-0235
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:
9218 SO. STATE ROAD 228
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACCLENNY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
36063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-259-4760
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICE
Authorized Official First Name:
BJ
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER ENROLLMENT SPECIALIST
Authorized Official Telephone Number:
479-277-9835

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 112596656 . 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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