Healthcare Provider Details

I. General information

NPI: 1902771173
Provider Name (Legal Business Name): WAL-MART STORES EAST , LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W KENOSHA ST
BROKEN ARROW OK
74012-8912
US

IV. Provider business mailing address

1 CUSTOMER DR
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 918-505-6908
  • Fax: 918-505-6909
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: KIMBERLY CANONIC
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 479-371-1168