Healthcare Provider Details

I. General information

NPI: 1477908770
Provider Name (Legal Business Name): WAL-MART STORES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 W MCCORD ST
CENTRALIA IL
62801-5648
US

IV. Provider business mailing address

702 SW 8TH ST MAILSTOP 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 479-204-8705
  • Fax:
Mailing address:
  • Phone: 479-204-8550
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAURA LEVINE
Title or Position: DIR. HEALTHCARE CONTRACT&ENROLLMENT
Credential:
Phone: 479-204-8550