Organization
WAL-MART STORES EAST LP
Active
Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-0736
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
120 SAM WALTON DR, RUSSELLVILLE, KY 42276-9311
(270) 726-2966
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
PO2105
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2031370
PK
—
05
—
5400752100
—
KY
05
—
5402292300
—
KY
Enumeration date
07/16/2006
Last updated
06/03/2025
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