Provider Demographics
NPI:1275913121
Name:WAL-MART STORES EAST, LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST, LP
Other - Org Name:WAL-MART VISION CENTER 30-3061
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-8705
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:
Mailing Address - Fax:
Practice Address - Street 1:7437 WATSON RD
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MO
Practice Address - Zip Code:63119-4415
Practice Address - Country:US
Practice Address - Phone:902-755-3092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-05
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1205213584Medicaid