Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-3713
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
3685 LADSON RD, LADSON, SC 29456-4304
(843) 879-5288
(843) 879-5287
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
16090
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2152263
PK
—
05
—
716092
—
SC
Enumeration date
05/29/2015
Last updated
04/20/2026
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