Healthcare Provider Details

I. General information

NPI: 1699279430
Provider Name (Legal Business Name): WAL-MART STORE EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 ROUTE 130 S
CINNAMINSON NJ
08077-3075
US

IV. Provider business mailing address

702 SW 8TH ST # MS 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 479-277-9170
  • Fax: 479-277-4331
Mailing address:
  • Phone: 479-277-9170
  • Fax: 479-277-4331

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: SARAH LITTLE
Title or Position: DIRECTOR OF HEALTHCARE CONTRACTING
Credential:
Phone: 479-277-2500