Provider Demographics
NPI:1922483155
Name:WAL-MART STORES TEXAS, LLC
Entity Type:Organization
Organization Name:WAL-MART STORES TEXAS, LLC
Other - Org Name:WALMART VISION CENTER 30-5987
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR HEALTHCARE ENROLLMENT&CONTRACT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-8550
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:MAILSTOP 0445
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 1:494 W. INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189
Practice Address - Country:US
Practice Address - Phone:479-204-8705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4360370515Medicare NSC