1235532045 NPI number — WAL-MART STORES EAST , LP

Table of content: (NPI 1235532045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235532045 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:
1235532045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2024
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:
479-204-8550
Provider Business Mailing Address Fax Number:
479-277-4331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 MCKEEN PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-4465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-267-3617
Provider Business Practice Location Address Fax Number:
318-267-3618
Provider Enumeration Date:
10/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MCMULLIN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
479-371-8711

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY.007035-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: 2203479 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2149160 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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