Basic Information
| Provider Information | |||||||||
| NPI: | 1235556150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES EAST LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WAL-MART PHARMACY 10-5888 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | MAILSTOP 0445 | ||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792772500 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 HARTZDALE DR | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170117213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174093109 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTHCARE CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | PP482472 | PA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2145984 | 01 | PK | OTHER | 1007455310373 | 05 | PA | MEDICAID |