Healthcare Provider Details

I. General information

NPI: 1417126467
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10392 FREMONT PIKE
PERRYSBURG OH
43551-3335
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 419-874-0590
  • Fax:
Mailing address:
  • Phone: 479-277-9373
  • Fax: 479-277-8176

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 ASSOCIATE
Credential:
Phone: 479-277-9373