MEDICARE: WAL-MART STORES EAST LP

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	156FX1800X	Optician
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1023108594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES EAST LP

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-1238
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	1525 GLEN SCHOOL RD
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704
Country	:	US
Telephone Number	:	919-688-3259
Fax Number	:

Authorized Official
Title or Position	:	ENROLLMENT SPECIALIST
Name	:	DIANNA M. PAINTER
Credential	:
Telephone Number	:	479-277-1238

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/07/2011

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