Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-4440
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
1180 DUTCH FORK RD, IRMO, SC 29063-8874
(803) 781-7877
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
—
—
3336C0003X
Community/Retail Pharmacy
Primary
10529
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1093942906
—
SC
01
—
2120751
PK
—
Enumeration date
06/18/2009
Last updated
07/11/2025
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