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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114002052
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	:	72716-6209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7450 CYPRESS GARDENS BLVD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-3247
Country	:	US
Telephone Number	:	863-318-0752
Fax Number	:

Authorized Official
Title or Position	:	NPI COORDINATOR
Name	:	NICOLE D GENTILE
Credential	:
Telephone Number	:	316-788-5580

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	09/11/2025

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