Organization
WAL-MART STORES EAST LP
Active
Other names
Wal-Mart Pharmacy 10-3067
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
4975 JIMMY CARTER BLVD, NORCROSS, GA 30093-3520
(770) 225-9906
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 204-8550
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009940
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003136989A
—
GA
01
—
2140658
PK
—
Enumeration date
06/04/2013
Last updated
06/05/2025
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