Organization
WAL-MART STORES EAST LP
Active
Other names
WALMART PHARMACY 10-1072
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
1830 US HIGHWAY 82 W, TIFTON, GA 31793-8164
(229) 386-0374
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
PHRE006808
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00352448A
—
GA
01
—
2015305
PK
—
Enumeration date
07/16/2006
Last updated
06/04/2025
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