Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-2214
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
5420 FOREST DR, COLUMBIA, SC 29206-5401
(803) 782-8428
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
3310
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2090789
PK
—
05
—
733106
—
SC
Enumeration date
07/16/2006
Last updated
06/09/2025
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