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Organization
WAL-MART STORES EAST LP
Active
Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-5419
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
2600 MCINGVALE RD, HERNANDO, MS 38632-8658
(662) 429-8767
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
06499
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01529571
—
MS
05
—
1529571
—
MS
01
—
2047118
PK
—
Enumeration date
07/16/2006
Last updated
06/13/2025
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