Organization
WAL-MART STORES EAST LP
Active
Other names
WalMart Pharmacy 10-5812
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
97 COMMERCE DR, BLUE RIDGE, GA 30513-3677
(706) 632-9508
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-2500
(479) 277-4331
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE010000
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003145873A
—
GA
01
—
2144756
PK
—
Enumeration date
02/14/2014
Last updated
06/06/2025
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