Healthcare Provider Details

I. General information

NPI: 1780767061
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 EUREKA TOWNE CENTER DR
EUREKA MO
63025-1031
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 636-587-9775
  • Fax: 636-587-9796
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MATT MCMULLIN
Title or Position: DIR ENROLLMENT CONTRACTING
Credential:
Phone: 479-371-8711