Provider Demographics
NPI:1588904593
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:SPECIALIST PLAN ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-204-6375
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-204-3675
Mailing Address - Fax:
Practice Address - Street 1:15495 PANAMA CITY BEACH PKY
Practice Address - Street 2:
Practice Address - City:PANAMA BEACH CITY
Practice Address - State:FL
Practice Address - Zip Code:32413
Practice Address - Country:US
Practice Address - Phone:850-708-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAL-MART STORES EAST LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty