Basic Information
Provider Information | |||||||||
NPI: | 1477938025 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAL-MART STORES EAST, LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WALMART VISION CENTER 30-5463 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 702 SW 8TH ST | ||||||||
Address2: |   | ||||||||
City: | BENTONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727160445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792582115 | ||||||||
FaxNumber: | 4792774331 | ||||||||
Practice Location | |||||||||
Address1: | 1220 THEIL ST | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | WI | ||||||||
PostalCode: | 530271448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622236014 | ||||||||
FaxNumber: | 2626705044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2015 | ||||||||
LastUpdateDate: | 09/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAUVER | ||||||||
AuthorizedOfficialFirstName: | DEB | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIALIST PLAN ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 4792582115 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WAL-MART STORES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.