MEDICARE: WAL-MART STORES, INC.

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	:	1720169261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES, INC.

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	:	11619 ISLAND AVE
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-8459
Country	:	US
Telephone Number	:	541-633-9720
Fax Number	:

Authorized Official
Title or Position	:	CONTRACT COORDINATOR
Name	:	TAMMY J BOYD
Credential	:
Telephone Number	:	479-277-1359

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	09/11/2025

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