MEDICARE: WAL-MART STORES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1003964776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES, INC

Provider Business Mailing Address
First Line	:	702 SW 8TH STREET
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0235
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 WADSWORTH BLVD
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80226-1510
Country	:	US
Telephone Number	:	303-205-0772
Fax Number	:	303-205-0774

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT SPECIALIST
Name	:	MR. G WESLEY CRAINSHAW III
Credential	:
Telephone Number	:	479-277-1850

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	09/13/2007

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