Wal-Mart Stores East LP

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

60005426A Issued in IN

Legal business name

WAL-MART STORES EAST LP

Practice address

3701 Portage Ave
South Bend, IN 46628-6098

Phone

(574) 243-5849

NPI assigned

Jul 16, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Sarah Little

Title

Director of Healthcare Contracting

Phone

(479) 277-2500

Specialties & licenses 3

Addresses

Other identifiers 3

Other names 1

• WAL-MART PHARMACY 10-2680 Doing business as

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

• Sams East Inc

  • Community/Retail Pharmacy
  • Hudson, NH
  • NPI 1982621009

  Member Of

  NPD member
• Walmart Inc.

  • Community/Retail Pharmacy
  • Pearl City, HI
  • NPI 1174541650

  Member Of

  NPD member

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487203200000",
    "number": "1104843325",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 SW 8TH ST",
            "city": "BENTONVILLE",
            "state": "AR",
            "postal_code": "727160445"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3701 PORTAGE AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466286098",
            "telephone_number": "574-243-5849"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2017-02-16",
        "status": "A",
        "authorized_official_last_name": "LITTLE",
        "authorized_official_first_name": "SARAH",
        "authorized_official_title_or_position": "DIRECTOR OF HEALTHCARE CONTRACTING",
        "authorized_official_telephone_number": "479-277-2500"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IN",
            "license": "60005426A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2024164",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200220460",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200220460A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WAL-MART PHARMACY 10-2680",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Sydney Wagner, MSW
• Tiffany Anne Wagoner, RBT
• Tricia L Wainscott, MSW
• Bethany Ann Wait, DO
• Brooke Waite
• Wal-Mart Stores East LP
• Wal-Mart Stores East, LP
• Wal-Mart Stores East, LP
• Jordan Leah Walczewski, NP
• Ainsley Easton Walden

• All providers in South Bend, IN
• Community/Retail Pharmacy in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 16, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.