1215956222 NPI number — WAL-MART STORES TEXAS LLC

Table of content: (NPI 1215956222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215956222 NPI number — WAL-MART STORES TEXAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAL-MART STORES TEXAS LLC
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:
1215956222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2019
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:
479-277-1258
Provider Business Mailing Address Fax Number:
479-277-4331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 W TRINITY MILLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75006-1375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-273-3455
Provider Business Practice Location Address Fax Number:
800-406-8976
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LITTLE
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF HEALTHCARE CONTRACTING
Authorized Official Telephone Number:
479-277-2500

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  99-200 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 28RO00006000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: TX377 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 400-0003 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 126 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 261465 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 22-01391 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHA-MOP-LIC-37 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2002012999 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 3242 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054.013662 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 4785OS , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 64000067A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 03779/7.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: OS01265 , 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: 200538680A , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810011244 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 613556 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH386 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166999407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2095511 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1215956222 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6031421 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0162973 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0162973 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100243640D , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1020965500001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1215956222 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100037990 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4582517 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470020 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7T2283 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1215956222 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007759300 . 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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