Provider Demographics
NPI:1508920406
Name:WAL-MART STORES EAST, LP
Entity Type:Organization
Organization Name:WAL-MART STORES EAST, LP
Other - Org Name:VISION CENTER 30-4224
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-277-9373
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 1:201 ZELKOVA CT. NW
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613
Practice Address - Country:US
Practice Address - Phone:828-464-4664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty