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Organization
WAL-MART STORES EAST LP
Active
Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-1799
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
2950 NEW PINERY RD, PORTAGE, WI 53901-9225
(608) 742-1670
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
333600000X
Pharmacy
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
8184-42
WI
3336S0011X
Specialty Pharmacy
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2115251
PK
—
05
—
33186800
—
WI
Enumeration date
07/16/2006
Last updated
06/16/2025
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