Organization
WAL-MART STORES EAST LP
Active
Other names
WAL-MART PHARMACY 10-3781
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY CANONIC (SENIOR DIRECTOR, ENROLLMENT)
(480) 277-6348
Entity
Organization
Contact information
Practice address
4545 LAFAYETTE RD, INDIANAPOLIS, IN 46254-2033
(317) 328-0401
Mailing address
702 SW 8TH ST, BENTONVILLE, AR 72716-0445
(479) 277-1242
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
60006120A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200885740A
—
IN
01
—
2025713
PK
—
Enumeration date
11/23/2007
Last updated
07/08/2025
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