NPIMap

Wal-Mart Stores East LP

Organization Active NPI Community/Retail Pharmacy · Fulton, KY

NPI 1265459598 · NPPES record last updated Dec 1, 2023

Key facts

NPI
1265459598
Entity type
Organization (NPI type 2)
Primary specialty
Community/Retail Pharmacy 3336C0003X
License
P02579 (KY)
Legal business name
WAL-MART STORES EAST LP
Practice address
1405 Middle Rd
Fulton, KY 42041-7905
Phone
(270) 472-9802
NPI assigned
Jul 16, 2006
Organization subpart
No

Authorized official

Name
Matthew McMullin
Title
Director, Contracting
Phone
(479) 371-8711

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

Member of 2

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

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D2142931Wal-Mart Stores East, LP Dba Wal-Mart Pharmacy #10
1405 Middle Road, Fulton, KY 42041		Certificate of waiverJan 22, 2028

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Walmart Pharmacy 10-0106
1405 Middle Rd, Fulton, KY 42041-7905 · (270) 472-9802		 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Ostomy Supplies|Enteral Nutrients|Surgical Dressings Does not accept assignment
Participating since Jul 1, 2014

Medicare participation

Medicare fee-for-service enrollment
Enrolled (3 enrollments) in KY

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20100930004388 KY DME Supplier - Pharmacy 6204749997 Practice locations: Fulton, KY
O20130807000885 KY Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997
O20220901001467 KY Part B Supplier - Independent Clinical Laboratory 6204749997 This NPI is an additional NPI on the enrollment

National Provider Directory

Tax ID family
Ability Network (4,651 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X P02579 KY Yes

Addresses

Primary practice location

1405 Middle Rd
Fulton, KY 42041-7905

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers

IdentifierTypeStateIssuer
5402967300MedicaidKY
2031886OtherPK
5400720800MedicaidKY

Other names

  • WALMART PHARMACY 10-0106 Doing business as

Electronic endpoints

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Ability Network

Other providers in Fulton, KY

All providers in Fulton, KY · Community/Retail Pharmacy in Kentucky

Sources for this page

Verify at the official NPI Registry.