MEDICARE: WAL-MART STORES, 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	:	1457756546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES, INC

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	:

Provider Business Practice Location Address
First Line	:	3705 E SOUTH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-4521
Country	:	US
Telephone Number	:	562-582-1133
Fax Number	:	562-582-9049

Authorized Official
Title or Position	:	SPECIALIST PLAN ENROLLMENT
Name	:	DEB LAUVER
Credential	:
Telephone Number	:	479-258-2115

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	04/14/2015

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