Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-5422
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
500 E ALICE ST, BAINBRIDGE, GA 39819-4998
(229) 246-9551
(229) 246-9570
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 258-6180
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE008893
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003182075A
—
GA
01
—
2015668
PK
—
Enumeration date
07/16/2006
Last updated
06/13/2025
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