Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-5819
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
445 STATE ROAD 13, FRUIT COVE, FL 32259-3838
(904) 417-9089
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PH26936
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009251400
—
FL
01
—
2140947
PK
—
Enumeration date
06/10/2013
Last updated
06/10/2025
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