Provider Demographics
NPI:1285070342
Name:WAL-MART STORES EAST, LP
Entity type:Organization
Organization Name:WAL-MART STORES EAST, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIR H&W
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BADEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-2611
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-0445
Mailing Address - Country:US
Mailing Address - Phone:479-204-8741
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:4700 CUTLER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4096
Practice Address - Country:US
Practice Address - Phone:505-346-1661
Practice Address - Fax:505-346-0703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-16
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NMPH000035323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140472OtherPK
NM4355052576Medicare NSC