Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-1773
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (CMS ESMD EMDR)
(480) 853-0515
Entity
Organization
Contact information
Practice address
12401 JEFFERSON AVE, NEWPORT NEWS, VA 23602-4311
(757) 874-4722
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
0201003071
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2105890
PK
—
05
—
6030621
—
VA
05
—
8572097
—
VA
Enumeration date
07/16/2006
Last updated
06/17/2025
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