Basic Information
| Provider Information | |||||||||
| NPI: | 1215956222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES TEXAS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WALMART PHARMACY 10-2625 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792771258 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 W TRINITY MILLS RD | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750061375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002733455 | ||||||||
| FaxNumber: | 8004068976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTHCARE CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 261465 | MN | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 22-01391 | KS | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 99-200 | OK | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 28RO00006000 | NJ | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | TX377 | KY | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | PHA-MOP-LIC-37 | MT | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 400-0003 | SD | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 126 | NE | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 2002012999 | MO | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 3242 | TN | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 054.013662 | IL | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 4785OS | LA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 64000067A | IN | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | 03779/7.1 | MS | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | OS01265 | AR | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 200538680A | 05 | TX | MEDICAID | 3810011244 | 05 | WV | MEDICAID | 613556 | 05 | TX | MEDICAID | PH386 | 05 | TX | MEDICAID | 166999407 | 05 | AR | MEDICAID | 2095511 | 01 | PK | OTHER | 1215956222 | 05 | TX | MEDICAID | 6031421 | 05 | WA | MEDICAID | 0162973 | 05 | NJ | MEDICAID | 0162973 | 05 | TX | MEDICAID | 100243640D | 05 | TX | MEDICAID | 1020965500001 | 05 | PA | MEDICAID | 1215956222 | 05 | MT | MEDICAID | 7100037990 | 05 | KY | MEDICAID | 4582517 | 05 | TN | MEDICAID | 470020 | 05 | TX | MEDICAID | 7T2283 | 05 | SC | MEDICAID | 1215956222 | 05 | VA | MEDICAID |