Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3403
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
3615 MARIETTA HWY, DALLAS, GA 30157-9472
(770) 445-9096
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
PHRE009000
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000940541Q
—
GA
05
—
00940541Q
—
GA
01
—
2016149
PK
—
05
—
PHRE009000
—
GA
Enumeration date
07/16/2006
Last updated
06/19/2025
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