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	332H00000X	Eyewear Supplier
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1548415516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAL-MART STORES INC.

Provider Business Mailing Address
First Line	:	702 SW 8RH ST
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72716-0235
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5565 20TH ST
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32966-4632
Country	:	US
Telephone Number	:	772-978-9385
Fax Number	:

Authorized Official
Title or Position	:	CONTRACT COORDINATOR
Name	:	MS. SONYA M HURD
Credential	:
Telephone Number	:	479-204-8932

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	11/18/2008

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