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NPI Code Detail

MEDICARE: WAL-MART STORES LOUISIANA, LLC

MEDICARE: WAL-MART STORES LOUISIANA, 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
1156FX1800XOptician
2332H00000XEyewear Supplier

General Provider Information

NPI Number : 1225111354
Entity Type Code : Organization
Provider Name (Legal Business Name) : WAL-MART STORES LOUISIANA, LLC
Provider Business Mailing Address
First Line : 702 SW 8TH ST.
Second Line :
City : BENTONVILLE
State : AR
Zip : 72716-0235
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1125 N PINE ST
Second Line :
City : DERIDDER
State : LA
Zip : 70634-2819
Country : US
Telephone Number : 337-462-0259
Fax Number :
Authorized Official
Title or Position : NPI COORDINATOR
Name : NICOLE D GENTILE
Credential :
Telephone Number : 316-788-5580
Provider Enumeration Date : 10/23/2006
Last Update Date : 09/11/2025

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