Organization
WAL-MART STORES EAST LP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
73 FELLOWSHIP, MT LAUREL, NJ 08054
(856) 372-6135
(856) 372-6131
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
Primary
28RS00764100
NJ
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2176008
PK
—
Enumeration date
01/08/2018
Last updated
06/12/2025
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