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	:	1275717001
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	:	479-277-9373
Fax Number	:	479-277-8176

Provider Business Practice Location Address
First Line	:	4545 LAFAYETTE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-2033
Country	:	US
Telephone Number	:	317-328-0398
Fax Number	:

Authorized Official
Title or Position	:	NPI ASSOCIATE
Name	:	DAVID J SIMMONS
Credential	:
Telephone Number	:	479-277-9373

Provider Enumeration Date	:	12/28/2007
Last Update Date	:	12/28/2007

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