Basic Information
| Provider Information | |||||||||
| NPI: | 1225141526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAL-MART STORES EAST, LP | ||||||||
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| OtherOrganizationName: | WALMART VISION CENTER 30-2586 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | MS 0445 | ||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792048550 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 WALDEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168963708 | ||||||||
| FaxNumber: | 7168963747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR CONTRACTING, HEALTH & WELL | ||||||||
| AuthorizedOfficialTelephone: | 4792048550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAL-MART STORES EAST, LP | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 332H00000X | NY | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 156FX1800X | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.