Organization
WAL-MART STORES EAST LP
Active
Other names
Walmart Pharmacy 10-5198
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
1810 TIFT AVE N, TIFTON, GA 31794-3542
(229) 339-8485
(229) 339-8489
Mailing address
702 SW 8TH ST, MAILSTOP 0445, BENTONVILLE, AR 72716-0445
(479) 204-8550
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE010185
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003168358A
—
GA
01
—
2153986
PK
—
Enumeration date
06/26/2015
Last updated
06/11/2025
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