MEDICARE: WAL-MART STORES TEXAS, LLC

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	:	1184083487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES TEXAS, LLC

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-1242
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	24403 IH 10 W
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1447
Country	:	US
Telephone Number	:	210-276-2527
Fax Number	:	210-276-2498

Authorized Official
Title or Position	:	ENROLLMENT SPECIALIST
Name	:	SHANNON FARMER
Credential	:
Telephone Number	:	479-277-1242

Provider Enumeration Date	:	02/15/2016
Last Update Date	:	06/15/2026

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