Provider Demographics
NPI:1801072244
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:MGR OF GOVERNMENT CONTRACTING
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 1:22209 ROCKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1554
Mailing Address - Country:US
Mailing Address - Phone:216-587-0110
Mailing Address - Fax:
Practice Address - Street 1:22209 ROCKSIDE RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-1554
Practice Address - Country:US
Practice Address - Phone:216-587-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-16
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
OH0217912503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2081105OtherPK