1770982217 NPI number — WAL-MART STORES EAST LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770982217 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:
1770982217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2015
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:
MAILSTOP 0445
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:
952 E LAWRENCE HARRIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLOCOMB
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36375-5350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-886-9500
Provider Business Practice Location Address Fax Number:
334-886-9506
Provider Enumeration Date:
08/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINE
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR. HEALTHCARE CONTRACT&ENROL
Authorized Official Telephone Number:
479-204-8550

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 114434 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1770982217 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2148085 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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