Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-3348
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
101 N CONGRESS AVE, LAKE PARK, FL 33403-3804
(561) 842-8966
(479) 277-4331
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PH22156
FL
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
031653100
—
FL
05
—
031653101
—
FL
05
—
031656300
—
FL
01
—
2006894
PK
—
Enumeration date
08/27/2006
Last updated
06/19/2025
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