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	:	1194256768
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	:	MS 0445
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-2500
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	5001 NINE MILE RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23223-5732
Country	:	US
Telephone Number	:	804-253-0687
Fax Number	:	804-253-1505

Authorized Official
Title or Position	:	DIR HEALTHCARE CONTRACT & ENROLL
Name	:	SARAH C LITTLE
Credential	:
Telephone Number	:	479-277-2500

Provider Enumeration Date	:	03/24/2017
Last Update Date	:	03/24/2017

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