Healthcare Provider Details

I. General information

NPI: 1477634921
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 STATE ROAD 136
BARABOO WI
53913-9254
US

IV. Provider business mailing address

702 SW 8TH STREET
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-1765
  • Fax: 608-356-0260
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: LINDA M. EPPERSON
Title or Position: NPI COORDINATOR
Credential:
Phone: 316-788-5580