Provider Demographics
NPI:1649329863
Name:WAL MART STORES, INC.
Entity type:Organization
Organization Name:WAL MART STORES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:G
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:CRAINSHAW
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:479-277-1850
Mailing Address - Street 1:702 SW 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 WESTERN AVE NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4504
Practice Address - Country:US
Practice Address - Phone:507-332-0232
Practice Address - Fax:507-333-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
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