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	156FX1800X	Optician
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1588756894
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	:	72716-0235
Country	:	US
Telephone Number	:	479-277-1359
Fax Number	:

Provider Business Practice Location Address
First Line	:	3133 E MAIN ST
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1521
Country	:	US
Telephone Number	:	914-526-1100
Fax Number	:

Authorized Official
Title or Position	:	CONTRACT COORDINATOR
Name	:	TAMMY J BOYD
Credential	:
Telephone Number	:	479-277-1359

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	09/11/2025

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