Basic Information
| Provider Information | |||||||||
| NPI: | 1730798851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAL-MART STORES EAST, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792772500 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 RT 10 SUITE A100 | ||||||||
| Address2: | |||||||||
| City: | LEDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732527666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2020 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH CARE CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
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 | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.