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NPI Code Detail

MEDICARE: WAL-MART STORES EAST, LP

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
1156FX1800XOptician

General Provider Information

NPI Number : 1609805829
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 : MAIL STOP 0235
City : BENTONVILLE
State : AR
Zip : 72716-6209
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2501 WEST AVE
Second Line :
City : RICE LAKE
State : WI
Zip : 54868-6000
Country : US
Telephone Number : 715-236-7642
Fax Number :
Authorized Official
Title or Position : SUPERVISOR
Name : LAURIE HAYNES
Credential :
Telephone Number : 479-204-8495
Provider Enumeration Date : 07/01/2006
Last Update Date : 08/22/2020

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