Provider Demographics
NPI:1225191901
Name:WAL-MART STORES EAST, LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST, LP
Other - Org Name:WAL-MART VISION CENTER 30-0847
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BJ
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-9835
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-6209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 LEFFLER ST.
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533
Practice Address - Country:US
Practice Address - Phone:608-935-7452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Not Answered332H00000XSuppliersEyewear Supplier