Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-1766
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
3100 JOHNSON FERRY RD, MARIETTA, GA 30062-5657
(770) 642-8466
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
PHRE007376
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00484899A
—
GA
01
—
2017793
PK
—
Enumeration date
07/16/2006
Last updated
06/17/2025
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