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	332H00000X	Eyewear Supplier
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1235913922
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	:	479-371-2827
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	5401 TINKER DIAG ST
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-4622
Country	:	US
Telephone Number	:	405-898-6556
Fax Number	:	405-898-6550

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MATTHEW MCMULLIN
Credential	:
Telephone Number	:	479-371-8711

Provider Enumeration Date	:	08/23/2023
Last Update Date	:	08/23/2023

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