Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-6964
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
4150 GOODMAN RD, HORN LAKE, MS 38637-0300
(662) 253-6181
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 204-8550
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
14511
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05176742
—
MS
01
—
2155037
PK
—
Enumeration date
10/08/2015
Last updated
06/09/2025
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