Basic Information
| Provider Information | |||||||||
| NPI: | 1043494933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES TEXAS, LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAL-MART OPTICAL HOME OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792771850 | ||||||||
| FaxNumber: | 4792778176 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 SW 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792771850 | ||||||||
| FaxNumber: | 4792778176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 12/27/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAINSHAW | ||||||||
| AuthorizedOfficialFirstName: | WES | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTICAL PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4792771850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 156FX1800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.