Provider Demographics
NPI:1225227820
Name:WAL-MART SUPERCENTER 1277
Entity Type:Organization
Organization Name:WAL-MART SUPERCENTER 1277
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VISION CENTER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-284-1592
Mailing Address - Street 1:611 STATE HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5453
Mailing Address - Country:US
Mailing Address - Phone:715-284-1592
Mailing Address - Fax:715-284-1604
Practice Address - Street 1:611 STATE HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5453
Practice Address - Country:US
Practice Address - Phone:715-284-1592
Practice Address - Fax:715-284-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier