Organization
WALMART INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
4700 135TH ST, CRESTWOOD, IL 60418-1405
(708) 489-6476
(708) 489-6898
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
054015822
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2021908
PK
—
05
—
54015822
—
IL
Enumeration date
07/17/2006
Last updated
07/02/2025
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