Healthcare Provider Details

I. General information

NPI: 1548415516
Provider Name (Legal Business Name): WAL-MART STORES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 20TH ST
VERO BEACH FL
32966-4632
US

IV. Provider business mailing address

702 SW 8RH ST
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 772-978-9385
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. SONYA M HURD
Title or Position: CONTRACT COORDINATOR
Credential:
Phone: 479-204-8932