MEDICARE: WAL-MART STORES EAST, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1104274307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST, LP

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:	MAILSTOP 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-204-8550
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	733 FASHION DRIVE
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-0000
Country	:	US
Telephone Number	:	803-223-0778
Fax Number	:

Authorized Official
Title or Position	:	DIR HEALTHCARE CONTRACT & ENROLL
Name	:	LAURA LEVINE
Credential	:
Telephone Number	:	479-204-8550

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	05/27/2016

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