NPIMap

Organization Active NPI

Wal-Mart Stores East LP

  • Community/Retail Pharmacy
  • Philadelphia, MS
National Provider Identifier
1790702199
Registry record updated Dec 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
01829 Issued in MS
Legal business name
WAL-MART STORES EAST LP
Practice address
1002 W Beacon St
Philadelphia, MS 39350-3204
Phone
(601) 656-5310
NPI assigned
Jul 16, 2006
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Matthew McMullin
Title
Director Contracting
Phone
(479) 371-8711

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2127876Walmart Pharmacy 10-02051002 W Beacon St, Philadelphia, MS 39350Certificate of waiverMar 20, 2027

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930032478 MS DME Supplier - PharmacyDME Supplier - Optician 6204749997 Practice locations: Philadelphia, MS
O20130913000150 MS Part B Supplier - Mass Immunization (Roster Biller Only) 6204749997 This NPI is an additional NPI on the enrollment
Practice locations: Canton, MS; Yazoo City, MS; Tupelo, MS; Starkville, MS; Ocean Springs, MS; Diberville, MS; Corinth, MS; Biloxi, MS…

National Provider Directory

National Provider Directory
Tax ID family
Ability Network4,651 organizations share this tax ID, including this one

Member of 2

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

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

Specialties & licenses 3

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 01829 MS Primary

Addresses

NPPES NPI Registry

Primary practice location

1002 W Beacon St
Philadelphia, MS 39350-3204

Mailing address

702 SW 8TH St
Bentonville, AR 72716-0445

Other identifiers 3

NPPES NPI Registry
IdentifierTypeStateIssuer
08355234MedicaidMS
8355234MedicaidMS
2044883OtherPK

Other names 1

NPPES NPI Registry
  • WALMART PHARMACY 10-0205 Doing business as

Electronic endpoints 1

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

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Dec 1, 2023.

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701388800000",
    "number": "1790702199",
    "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": "1002 W BEACON ST",
            "city": "PHILADELPHIA",
            "state": "MS",
            "postal_code": "393503204",
            "telephone_number": "601-656-5310"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2023-12-01",
        "certification_date": "2023-12-01",
        "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": "MS",
            "license": "01829",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "08355234",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8355234",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2044883",
            "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 Ste 900A",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "WALMART PHARMACY 10-0205",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALMART PHARMACY 10-0205",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Philadelphia, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.