Healthcare Provider Details

I. General information

NPI: 1619384690
Provider Name (Legal Business Name): WAL-MART STORES TEXAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 S COOPER ST
ARLINGTON TX
76017-5928
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 817-557-8706
  • Fax: 817-557-8740
Mailing address:
  • Phone: 479-204-8550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAURA LEVINE
Title or Position: DIRECTOR OF HEALTHCARE CONTRACTING
Credential:
Phone: 479-204-8550