Healthcare Provider Details

I. General information

NPI: 1578644274
Provider Name (Legal Business Name): WAL-MART STORES TEXAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 N HIGHWAY 377
ROANOKE TX
76262-9122
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 682-831-9338
  • 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: MANAGER, GOV'T CONTRACTING
Credential:
Phone: 479-204-8550