Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-5745
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
175 HIGHWAY 274, LAKE WYLIE, SC 29710-6045
(803) 619-7028
(803) 619-7022
Mailing address
1 CUSTOMER DR, MS 0445, BENTONVILLE, AR 72716-0445
(479) 277-1238
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
11102
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1326366493
—
SC
01
—
2125156
PK
—
Enumeration date
05/13/2010
Last updated
09/29/2025
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