Healthcare Provider Details

I. General information

NPI: 1568548766
Provider Name (Legal Business Name): WALMART STORES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 W KETTLEMAN LN
LODI CA
95242-9762
US

IV. Provider business mailing address

1 CUSTOMER DR, MS 0445
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 209-368-6696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: KIMBERLY CANONIC
Title or Position: SR. DIRECTOR
Credential:
Phone: 479-371-1168