Organization
WAL-MART STORES EAST, LP
Active
Parent organization
WAL-MART STORES, INC.
Other names
Walmart Care Clinic 10-1339
Organization subpart
Yes
Provider details
NPI number
Legal business name
WAL-MART STORES, INC.
Authorized official
LAURA LEVINE (DIRECTOR OF HEALTHCARE CONTRACTING)
(479) 204-8550
Entity
Organization
Contact information
Practice address
10060 TWO NOTCH RD, COLUMBIA, SC 29223-4396
(803) 567-6338
(803) 736-6204
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 204-8550
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
D953
MEDICARE PTAN
SC
05
—
GP6567
—
SC
Enumeration date
09/11/2014
Last updated
02/19/2015
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