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Organization
WAL-MART STORES EAST LP
Active
Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-5383
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
615 BULTMAN DR, SUMTER, SC 29150-2514
(803) 305-6194
(803) 305-6197
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 258-6180
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
16204
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2154299
PK
—
05
—
716205
—
SC
Enumeration date
09/17/2015
Last updated
06/12/2025
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