Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-5363
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
11465 TARA BLVD, LOVEJOY, GA 30250
(770) 471-5055
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
PHRE008891
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2015666
PK
—
05
—
685531783A
—
GA
Enumeration date
07/17/2006
Last updated
06/13/2025
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