Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3732
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
901 UNSER BLVD SE, RIO RANCHO, NM 87124-6365
(505) 962-9239
(505) 962-9242
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PH00002810
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2058995
PK
—
05
—
65137752
—
NM
05
—
PH2810
—
NM
Enumeration date
07/16/2006
Last updated
07/08/2025
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