Organization
WAL-MART STORES EAST LP
Active
Other names
Wal-Mart Pharmacy 10-1906
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 853-0515
Entity
Organization
Contact information
Practice address
42 FAIRHAVEN COMMONS WAY, FAIRHAVEN, MA 02719-4627
(508) 993-4250
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(508) 993-8100
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
DS3603
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0416711
—
MA
01
—
2116612
PK
—
Enumeration date
08/01/2008
Last updated
06/11/2025
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