Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY10-0314
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
1224 HUNTSVILLE HWY, FAYETTEVILLE, TN 37334-3618
(931) 433-0011
(931) 433-0147
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2155
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1454018
—
TN
01
—
2090954
PK
—
Enumeration date
07/16/2006
Last updated
05/30/2025
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