Healthcare Provider Details

I. General information

NPI: 1396858189
Provider Name (Legal Business Name): WAL-MART STORES EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 RETAIL CIR
MORGANTOWN WV
26508-1646
US

IV. Provider business mailing address

702 SW 8TH ST MS 0445
BENTONVILLE AR
72716-0235
US

V. Phone/Fax

Practice location:
  • Phone: 304-292-9887
  • Fax: 304-292-9889
Mailing address:
  • Phone: 479-204-8550
  • 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: LAURA LEVINE
Title or Position: DIR HEALTHCARE CONTRACT & ENROLL
Credential:
Phone: 479-204-8550