NPIMap

Organization Active NPI

Wal-Mart Stores East LP

Doing business as Walmart Pharmacy 10-0014

  • Community/Retail Pharmacy
  • Lebanon, MO
National Provider Identifier
1417974833
Registry record updated Nov 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
2002009385 Issued in MO
Legal business name
WAL-MART STORES EAST LP
Doing business as
Walmart Pharmacy 10-0014
Practice address
1800 S Jefferson Ave
Lebanon, MO 65536-4208
Phone
(417) 532-7148
NPI assigned
Jul 16, 2006
Last updated
Nov 6, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 6, 2023

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

Authorized official

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 2002009385 MO Primary

Addresses

Primary practice location

1800 S Jefferson Ave
Lebanon, MO 65536-4208

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers 2

IdentifierTypeStateIssuer
601294309MedicaidMO
2050048OtherPK

Other names 1

  • WALMART PHARMACY 10-0014 Doing business as

Electronic endpoints 1

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930071515 MO DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Lebanon, MO
O20131102000102 MO Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4,659 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Member of 2

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

  • Sams East Inc

    dba Sams Pharmacy

    • Community/Retail Pharmacy
    • San Antonio, TX
    • NPI 1932126059

    Member Of

    NPD member
  • Walmart Inc.

    dba Walmart Pharmacy 10-2050

    • Community/Retail Pharmacy
    • Henderson, NV
    • NPI 1043237142

    Member Of

    NPD member

NPI Registry JSON

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

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699228800000",
    "number": "1417974833",
    "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": "1800 S JEFFERSON AVE",
            "city": "LEBANON",
            "state": "MO",
            "postal_code": "655364208",
            "telephone_number": "417-532-7148"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2023-11-06",
        "certification_date": "2023-11-06",
        "status": "A",
        "authorized_official_last_name": "MCMULLIN",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "DIRECTOR, CONTRACTING",
        "authorized_official_telephone_number": "479-371-8711"
    },
    "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": "MO",
            "license": "2002009385",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "601294309",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2050048",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "affiliationName": "Ability Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 N 6th St",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031505",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "WALMART PHARMACY 10-0014",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALMART PHARMACY 10-0014",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lebanon, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 6, 2023; 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.