Organization
WAL-MART STORES EAST LP
Active
Other names
Wal-Mart Pharmacy 10-3303
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
1179 RIVERVIEW ST, GRUNDY, VA 24614-9481
(276) 244-3014
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-6209
(479) 277-1238
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
0201004421
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1063700409
—
VA
01
—
2131166
PK
—
Enumeration date
07/19/2011
Last updated
06/19/2025
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