# WAL-MART STORES EAST LP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** WALMART PHARMACY 10-0979
- **Organization subpart:** No

## Provider details

- **NPI number:** 1710904859
- **Authorized official:** KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
- **Authorized official phone:** (480) 277-6348

## Contact information

- **Practice address:** 1600 W WISCONSIN ST, SPARTA, WI 54656-2242
- **Practice address phone:** (608) 269-7843
- **Mailing address:** 702 SW 8TH ST, BENTONVILLE, AR 72716-0445
- **Mailing address phone:** (479) 277-1242

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 8326-42 | WI | Yes |
| 3336S0011X | Specialty Pharmacy | — | NULL | — |

## Other

- **Enumeration date:** 07/16/2006
- **Last updated:** 06/04/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2114603 | PK | — |
| 05 | — | 33063200 | — | WI |