WAL-MART PHARMACY 10-3609 (WAL-MART STORES EAST LP) NPI 1023295078

Pharmacy (Community/Retail Pharmacy) in Ellenwood, GA

NPI 1023295078 Organization Pharmacy Community/Retail Pharmacy Medicare Supplier Does Not Accept Medicare Approved Payment CLIA Number 11D2174912 CLIA Certificate of Waiver

About WAL-MART PHARMACY 10-3609 (WAL-MART STORES EAST LP)

Wal-mart Pharmacy 10-3609 (wal-mart Stores East Lp) is a provider established in Ellenwood, Georgia specializing in pharmacy (community/retail pharmacy) . The NPI number of Wal-mart Pharmacy 10-3609 (wal-mart Stores East Lp) is 1023295078 and was assigned on January 2008. The practitioner's primary taxonomy code is 3336C0003X with license number PHRE009458 (GA). The provider is registered as an organization and their NPI record was last updated 4 years ago. The provider's is doing business as Wal-mart Pharmacy 10-3609. The authorized official of this NPI record is Sarah Little (Director Of Healthcare Contracting)

Wal-mart Pharmacy 10-3609 is a medicare supplier with PTAN 4355052319 who does not accept Medicare assignment for all durable medical equipment and supplies. The provider may not accept the Medicare allowable as payment in full and may collect additional payment directly from the patient, and/or charge more than the Medicare allowable.The supplier carries the following product categories: Canes and/or Crutches or Ostomy Supplies or Prosthetic Lenses: Conventional Contact Lenses or Prosthetic Lenses: Conventional Eyeglasses or Blood Glucose Monitors/Supplies (Non-Mail Order) or Blood Glucose Monitors/Supplies (Mail Order) or Walkers or Enteral Nutrients or Surgical Dressings.

The CLIA number of Wal-mart Pharmacy 10-3609 is 11D2174912 registered as a "pharmacy" facility with a CLIA Certificate of Waiver. This CLIA certificate is issued to Wal-mart Pharmacy 10-3609 to perform only waived tests. CLIA defines waived tests as simple tests with a low risk for an incorrect result. Waived tests include certain tests listed in CLIA regulations, tests cleared by the FDA for home use and tests approved by the FDA for waived status and that meet CLIA waiver criteria.

NPI

1023295078

Provider NameWAL-MART PHARMACY 10-3609 (WAL-MART STORES EAST LP)
Provider Location Address2940 ANVIL BLOCK RD ELLENWOOD, GA 30294
Provider Mailing Address702 SW 8TH ST BENTONVILLE, AR 72716
NPI Entity TypeOrganization
Is Sole Proprietor?N/A
Is Organization Subpart?No
Other Organization NameWAL-MART PHARMACY 10-3609
Other Name TypeDoing Business As (3)
Enumeration Date01-22-2008
Last Update Date02-16-2017


Primary Taxonomy

Taxonomy Code3336C0003X
ClassificationPharmacy
TypeSuppliers
SpecializationCommunity/Retail Pharmacy
License No.PHRE009458
License StateGA
Taxonomy DescriptionA pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes.

Business Address

WAL-MART PHARMACY 10-3609
2940 ANVIL BLOCK RD
ELLENWOOD, GA
ZIP 30294
Phone: (404) 361-6961

Get Directions


Mailing Address

WAL-MART PHARMACY 10-3609
702 SW 8TH ST
BENTONVILLE, AR
ZIP 72716
Phone: (479) 204-8550
Fax: (479) 277-4331



Authorized Official

Authorized Official Name SARAH LITTLE
Authorized Official TitleDIRECTOR OF HEALTHCARE CONTRACTING
Authorized Official Phone(479) 277-2500

Medical Equipment Supplier

The provider carries the following medical supplies product categories:

PTAN4355052319
Accepts Medicare AssignmentNO
Specialities ListPharmacy.
Supplies List
  • Canes and/or Crutches - Standard Canes, Quad Canes, Offset Canes, Standard Crutches, Forearm Crutches
  • Ostomy Supplies - Pouches, Paste, Powder, Barrier wipes
  • Prosthetic Lenses: Conventional Contact Lenses - Conventional Contact Lenses
  • Prosthetic Lenses: Conventional Eyeglasses - Conventional Eyeglasses
  • Blood Glucose Monitors/Supplies (Non-Mail Order) - Home blood glucose monitors including lancets, reagent strips, and other supplies necessary for the proper functioning of the device
  • Blood Glucose Monitors/Supplies (Mail Order) - Home blood glucose monitors including lancets, reagent strips, and other supplies necessary for the proper functioning of the device
  • Walkers - Standard Walkers, Wheeled Walkers, Folding Walker
  • Enteral Nutrients - Enteral formula
  • Surgical Dressings - Gauze, Elastic bandages, Adhesive tape
Competitive BiddingNO

CLIA Information

The Clinical Laboratory Improvement Amendments (CLIA) of 1988 applies to facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. The CLIA Program sets standards for clinical laboratory testing and issues certificates. The NPI / CLIA crosswalk information for the NPI number 1023295078 is:

CLIA Number11D2174912
Facility TypePHARMACY
Certificate TypeCertificate of Waiver

Secondary Taxonomies


The secondary taxonomy codes define the provider type, classification, and specialization. For individual NPIs the license data is associated to each taxonomy code.

No. Taxonomy Code Type Classification Specialization License No. State Primary
1332B00000XSuppliersDurable Medical Equipment & Medical SuppliesNo

Taxonomy Description: a supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient's use in the home and that are usable for an extended period of time.

2333600000XSuppliersPharmacyNo

Taxonomy Description: a facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located.

Additional Identifiers


Additional identifier(s) currently or formerly used as an identifier for the provider. The codes may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.

Identifier Type / Code Identifier State
2017395OTHER (01)
095731884AMEDICAID (05)GA

NPI Footnotes

What is the National Provider Indentifier (NPI)?
The NPI is 10-position all-numeric identification number assigned by the NPPES to uniquely identify a health care provider.

Provider Location Address
The location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.

Provider Mailing Address
The mailing address of the provider being identified. This address may contain the same information as the provider location address.

Entity Type Code
The code describing the type of health care provider that is being assigned an NPI.
The entity type codes are:
1 = Person: individual human being who furnishes health care;
2 = Non-person: entity other than an individual human being that furnishes health care (Examples: hospital, SNF, hospital subunit, pharmacy, or HMO)

What is a Subpart?
Subparts are the components and separate physical locations of organization health care providers. Subpart examples include:
Hospital components include outpatient departments, surgical centers, psychiatric units, and laboratories. These components are often separately licensed or certified by States and may exist at physical locations other than that of the hospital of which they are a component.

Provider Other Organization Name
The other organization name is the alternative last name by which the provider is or has been known (if an individual) or other name by which the organization provider is or has been known. The code identifying the type of other name. The provider other organization name codes are:
1 = former name;
2 = professional name;
3 = doing business as (d/b/ a) name;
4 = former legal business name; :
5 = other.

Provider Enumeration Date
The date the provider was assigned a unique identifier (assigned an NPI).

Last Update Date
The date that a NPI record was last updated or changed.

Primary Taxonomy Code
The primary taxonomy code defines the provider type, classification, and specialization. There could be only one primary taxonomy code per NPI record. For individual NPIs the license data is associated to the taxonomy code.

Authorized Official Name
The name of the person authorized to submit the NPI application or to officially change data for a health care provider.