Wal-Mart Stores East LP

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PH25190 Issued in FL

Legal business name

WAL-MART STORES EAST LP

Practice address

1300 John Sims Pkwy E
Niceville, FL 32578-2208

Phone

(850) 839-3124

Fax

(850) 389-3014

NPI assigned

Oct 27, 2010

Organization subpart

No

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

Authorized official

Name

Matt McMullin

Title

Director of Healthcare Contracting

Phone

(793) 718-7114

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• WalMart Pharmacy 10-5845 Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in FL, NC3 enrollments

Enrollment records 3

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Wal-Mart Stores East LP

  • Community/Retail Pharmacy
  • Raleigh, NC
  • NPI 1790085496

  O20111209000507

  Same enrollment

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": "1288137600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693267200000",
    "number": "1972803674",
    "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": "727166209",
            "telephone_number": "479-277-1238",
            "fax_number": "479-277-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 JOHN SIMS PKWY E",
            "city": "NICEVILLE",
            "state": "FL",
            "postal_code": "325782208",
            "telephone_number": "850-839-3124",
            "fax_number": "850-389-3014"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAL-MART STORES EAST LP",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-27",
        "last_updated": "2023-08-29",
        "certification_date": "2023-08-29",
        "status": "A",
        "authorized_official_last_name": "MCMULLIN",
        "authorized_official_first_name": "MATT",
        "authorized_official_title_or_position": "DIRECTOR OF HEALTHCARE CONTRACTING",
        "authorized_official_telephone_number": "793-718-7114"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "FL",
            "license": "PH25190",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2127457",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003180500",
            "state": "FL"
        }
    ],
    "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 10-5845",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WalMart Pharmacy 10-5845",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Olivia Victor, RBT
• Jodi L. Visi
• Hailey Lynn Wagner, PT, DPT
• Susan M Wagner, ARNP, CRNP, FNP-C
• Wal-Mart Stores East LP
• Walgreen Co
• Sherry Dawn Walker, L.P.N
• Anna Walsh
• Hannah Walters
• Deanna Walton

• Community/Retail Pharmacy in Niceville, FL
• Providers in Niceville, FL by specialty
• Community/Retail Pharmacy in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 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.