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	332H00000X	Eyewear Supplier
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1194048769
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	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0235
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 THREE SPRINGS DR
Second Line	:
City	:	WEIRTON
State	:	WV
Zip	:	26062-4950
Country	:	US
Telephone Number	:	304-723-3445
Fax Number	:

Authorized Official
Title or Position	:	CARRIER SPECIALIST
Name	:	HOLLY C WILKINSON
Credential	:
Telephone Number	:	479-204-8320

Provider Enumeration Date	:	03/10/2010
Last Update Date	:	03/10/2010

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