Healthcare Provider Details

I. General information

NPI: 1386819142
Provider Name (Legal Business Name): WAL-MART STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5695 HWY 95 N
LAKE HAVASU CITY AZ
86403-9646
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 928-764-3755
  • Fax: 928-472-2815
Mailing address:
  • Phone: 479-277-2500
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARAH LITTLE
Title or Position: DIRECTOR HEALTHCARE CONTRACTING
Credential:
Phone: 479-277-2500