MEDICARE: WAL-MART STORE, INC.

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	:	1386819142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORE, INC.

Provider Business Mailing Address
First Line	:	702 SW 8TH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0445
Country	:	US
Telephone Number	:	479-277-2500
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	5695 HWY 95 N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9646
Country	:	US
Telephone Number	:	928-764-3755
Fax Number	:	928-472-2815

Authorized Official
Title or Position	:	DIRECTOR HEALTHCARE CONTRACTING
Name	:	SARAH LITTLE
Credential	:
Telephone Number	:	479-277-2500

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	07/21/2022

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