Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3710
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
3580 MEMORIAL DR, DECATUR, GA 30032-2723
(404) 284-0707
Mailing address
702 SW 8TH ST, 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
PHRE009448
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2016885
PK
—
05
—
438906236A
—
GA
Enumeration date
01/22/2008
Last updated
07/02/2025
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