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NPI Code Detail

MEDICARE: WAL-MART STORES TEXAS, LLC

MEDICARE: WAL-MART STORES TEXAS, LLC
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
1156FX1800XOptician
2332H00000XEyewear Supplier

General Provider Information

NPI Number : 1790869360
Entity Type Code : Organization
Provider Name (Legal Business Name) : WAL-MART STORES TEXAS, LLC
Provider Business Mailing Address
First Line : 702 SW 8TH ST
Second Line :
City : BENTONVILLE
State : AR
Zip : 72716-0445
Country : US
Telephone Number : 479-204-8550
Fax Number : 479-277-4337
Provider Business Practice Location Address
First Line : 8520 N BEACH ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76244-4918
Country : US
Telephone Number : 817-514-6090
Fax Number : 817-514-9689
Authorized Official
Title or Position : MGR GOV CONTRACTING
Name : LAURA LEVINE
Credential :
Telephone Number : 479-204-8550
Provider Enumeration Date : 10/24/2006
Last Update Date : 06/26/2013

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