Basic Information
| Provider Information | |||||||||
| NPI: | 1972175271 | ||||||||
| 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: | 4792582115 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 W I 35 FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730347394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053488005 | ||||||||
| FaxNumber: | 4053300417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2021 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, HEALTH CARE CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
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.