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General NPI Number Information
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NPI Number | 1336513993
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Entity Type | Organization
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Legal Business Name | WAL-MART STORES EAST, LP
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Dates
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Enumeration Date | 11/19/2015
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 4701 NOTHPORT BLVD
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City | SHREVEPORT
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State | LA
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Zip | 71107
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Country | US
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Telephone | 318-929-9561
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Fax |
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Provider Business Mailing Address
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Address Line | 702 SW 8TH ST MAILSTOP 0445
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City | BENTONVILLE
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State | AR
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Zip | 72716-0445
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Country | US
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Telephone | 479-204-8550
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Fax |
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Authorized Official
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Title or Position | DIR HEALTHCARE CONTRACT&ENROLLMENR
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Name | LAURA LEVINE
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Credential |
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Telephone | 479-204-8550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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