Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-2939
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SR DIRECTOR, CONTRACTING)
(479) 371-1168
Entity
Organization
Contact information
Practice address
200 MARKETPLACE DR, RICHLAND, MS 39218-4429
(601) 939-2958
Mailing address
1 CUSTOMER DR # MS 0445, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
05061
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05851031
—
MS
01
—
2046298
PK
—
05
—
5851031
—
MS
Enumeration date
07/17/2006
Last updated
01/26/2026
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