Organization
WAL-MART STORES EAST , LP
Active
Other names
Walmart Pharmacy 10-4585
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
11551 N 129TH EAST AVE, OWASSO, OK 74055-7446
(918) 371-3585
(918) 371-3733
Mailing address
1 CUSTOMER DR # MS 0445, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2-7368
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100237380C
—
OK
01
—
2153495
PK
—
Enumeration date
06/04/2015
Last updated
04/10/2026
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