Healthcare Provider Details

I. General information

NPI: 1942381314
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 GEORGE CLAUSS BLVD
GLEN BURNIE MD
21144-4933
US

IV. Provider business mailing address

702 SW 8TH ST.
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 410-969-0705
  • 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: DAVID J SIMMONS
Title or Position: NPI COORDINATOR
Credential:
Phone: 479-277-9373