Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3831
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
1098 FREDERICK BLVD, PORTSMOUTH, VA 23707-4119
(757) 399-6150
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
0201004123
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010385661
—
VA
05
—
1588729552
—
VA
01
—
2106160
PK
—
Enumeration date
12/27/2006
Last updated
07/08/2025
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