Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3499
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
1520 S MAIN ST, JEFFERSON, WI 53549-2940
(920) 674-2873
(920) 674-2899
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-6209
(479) 204-8550
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8843042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2111112
PK
—
05
—
36227900
—
WI
Enumeration date
05/20/2008
Last updated
06/19/2025
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