Healthcare Provider Details

I. General information

NPI: 1922429836
Provider Name (Legal Business Name): WAL-MART STORES TEXAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11923 US HWY 290 E
MANOR TX
78653
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 479-204-8705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAURA LEVINE
Title or Position: DIRECTOR GOVERNMENT CONTRACTACTING
Credential:
Phone: 479-204-8550