Provider Demographics
NPI:1649673443
Name:WAL-MART STORES INC
Entity type:Organization
Organization Name:WAL-MART STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTHCARE CONTRAC
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-8550
Mailing Address - Street 1:702 SW 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-204-8550
Mailing Address - Fax:
Practice Address - Street 1:814 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:AR
Practice Address - Zip Code:72933-8907
Practice Address - Country:US
Practice Address - Phone:479-965-8503
Practice Address - Fax:479-965-8506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
ARAR207893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR207322407Medicaid
2149059OtherPK
AR207322407Medicaid