Provider Demographics
NPI:1053846345
Name:WAL-MART STORES EAST, LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST, LP
Other - Org Name:WALMART VISION CENTER 30-1566
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-1258
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-277-1242
Mailing Address - Fax:479-277-4331
Practice Address - Street 1:4024 ELKHART RD STE 2
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5801
Practice Address - Country:US
Practice Address - Phone:479-204-1258
Practice Address - Fax:479-277-4331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty