1720506967 NPI number — WAL-MART STORES EAST LP

Table of content: (NPI 1720506967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720506967 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:
1720506967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2018
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:
479-277-2500
Provider Business Mailing Address Fax Number:
479-277-4331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 S WOODLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32720-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-624-0679
Provider Business Practice Location Address Fax Number:
386-624-0680
Provider Enumeration Date:
09/08/2017

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PH31103 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 023541601 DME , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 023541600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2172763 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com