Provider Demographics
NPI:1780767061
Name:WAL-MART STORES EAST, LP
Entity type:Organization
Organization Name:WAL-MART STORES EAST, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR ENROLLMENT CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-371-8711
Mailing Address - Street 1:702 SW 8TH ST.
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 EUREKA TOWNE CENTER DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1031
Practice Address - Country:US
Practice Address - Phone:636-587-9775
Practice Address - Fax:636-587-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty