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	:	1447668223
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	:
Fax Number	:	479-277-4331

Provider Business Practice Location Address
First Line	:	2245 JACKSONBORO HWY
Second Line	:
City	:	FT. WORTH
State	:	TX
Zip	:	76114
Country	:	US
Telephone Number	:	479-277-4331
Fax Number	:

Authorized Official
Title or Position	:	DIR HEALTHCARE CONTRACTING
Name	:	LAURA LEVINE
Credential	:
Telephone Number	:	479-204-8550

Provider Enumeration Date	:	07/24/2014
Last Update Date	:	07/24/2014

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