Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3748
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
3826 COBB PKWY NW, ACWORTH, GA 30101-4022
(770) 966-1366
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009087
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
083384406A
—
GA
01
—
2016387
PK
—
Enumeration date
10/13/2006
Last updated
07/08/2025
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