Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 5774
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
6411 W PARK AVE, HOUMA, LA 70364-2238
(985) 217-3664
(985) 217-3663
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 204-8550
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHY.007357-RC
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2160931
PK
—
Enumeration date
05/24/2016
Last updated
06/10/2025
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