Basic Information
Provider Information | |||||||||
NPI: | 1265518534 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAL-MART STORES EAST, LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WALMART VISION CENTER 30-2399 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 725 GOLD STREET | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031033218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036219922 | ||||||||
FaxNumber: | 6036219760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2006 | ||||||||
LastUpdateDate: | 05/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEVINE | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR CONTRACTING, HEALTH & WELL | ||||||||
AuthorizedOfficialTelephone: | 4792048550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WAL-MART STORES EAST, LP | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 |   | NH | N |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   | 156FX1800X |   | NH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.