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	:	1821421835
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	:	72716-0445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8424 MALL PARKWAY
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-2979
Country	:	US
Telephone Number	:	770-482-2497
Fax Number	:	770-484-6603

Authorized Official
Title or Position	:	MANAGER OF GOVERNEMENT CONTRACTING
Name	:	LAURA LEVINE
Credential	:
Telephone Number	:	477-204-8550

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	08/16/2013

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