1235546482 NPI number — WAL-MART STORES EAST, LP

Table of content: (NPI 1235546482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235546482 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:
1235546482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2015
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:
479-204-8550
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2240 W DEKALB ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29020-2069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-900-6028
Provider Business Practice Location Address Fax Number:
803-425-7793
Provider Enumeration Date:
07/21/2014

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 CONTRACTING
Authorized Official Telephone Number:
479-204-8550

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D953 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP6566 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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