Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3750
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
502 BOOTH RD, WARNER ROBINS, GA 31088-3422
(478) 918-0678
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
PHRE009012
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2016256
PK
—
05
—
690968488A
—
GA
05
—
PHRE009012
—
GA
Enumeration date
07/17/2006
Last updated
07/08/2025
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