Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-1569
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
240 WAL MART WAY, MAYSVILLE, KY 41056-7516
(606) 759-5050
Mailing address
702 SW 8TH ST, MAIL STOP 0445, 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
PO2294
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2031660
PK
—
05
—
5400788500
—
KY
05
—
5402602600
—
KY
Enumeration date
07/16/2006
Last updated
07/14/2025
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