Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-3060
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
2129 GRAND AVE, YAZOO CITY, MS 39194-2312
(662) 673-4020
(662) 673-4031
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 277-2500
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
Primary
15069/1.2
MS
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02026858
—
MS
05
—
06080204 DME
—
IN
01
—
2167848
PK
—
Enumeration date
02/06/2017
Last updated
06/05/2025
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