# WAL-MART STORES EAST LP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Walmart Pharmacy 10-6174
- **Organization subpart:** No

## Provider details

- **NPI number:** 1881088656
- **Authorized official:** KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
- **Authorized official phone:** (480) 277-6348

## Contact information

- **Practice address:** 10635 DORCHESTER RD, SUMMERVILLE, SC 29485-7610
- **Practice address phone:** (843) 879-5150
- **Practice address fax:** (843) 879-5151
- **Mailing address:** 702 SW 8TH ST, MS 0445, BENTONVILLE, AR 72716-0445
- **Mailing address phone:** (479) 277-2500
- **Mailing address fax:** (479) 277-4331

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 16084 | SC | Yes |

## Other

- **Enumeration date:** 03/19/2015
- **Last updated:** 06/09/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2150892 | PK | — |
| 05 | — | 716084 | — | SC |