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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
1332H00000XEyewear Supplier
2156FX1800XOptician

General Provider Information

NPI Number : 1669641627
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 : 479-277-9373
Fax Number : 479-277-8176
Provider Business Practice Location Address
First Line : 5780 FRANKLIN ST
Second Line :
City : MICHIGAN CITY
State : IN
Zip : 46360-7844
Country : US
Telephone Number : 219-879-3620
Fax Number :
Authorized Official
Title or Position : NPI ASSOCIATE
Name : DAVID J SIMMONS
Credential :
Telephone Number : 479-277-9373
Provider Enumeration Date : 02/25/2008
Last Update Date : 02/25/2008

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