Healthcare Provider Details

I. General information

NPI: 1568545184
Provider Name (Legal Business Name): WAL-MART STORES EAST LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 S TAYLOR
SHEBOYGAN WI
53081-4206
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 920-459-8814
  • Fax:
Mailing address:
  • Phone: 479-277-1238
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DIANNA PAINTER
Title or Position: ENROLLMENT SPECIALIST
Credential:
Phone: 479-277-1238